Return to Home Page
  Company Profile
  Investigations
  Case Assignment
  Contact Us
   
  Maine License:
95-00746
New Hampshire License:
DA- 365

 

 


All major credit cards
accepted through PayPal

Client Information:    Fields marked * are required.
Company:
Your Name:
 First: *   Last: *
Your Address:
Primary Phone:
Ext:
Direct Line:
 Ext:
Fax:
Email Address:
 *
Case Information:
Date of Loss Your Claim # Other Claim # Insured Name
 
Assignment Type:
   
Budget:
   or   Hours Authorized:
Due Date:
Injury or Restrictions:
Claim Type:
Special Instructions:
   
Subject Represented  Sending Previous Report
Video Copy Requested Previous Surveillance
Verbal Report   Active Scheduled Appointment
   
Subject Information:
Company:
Name:
   First:  Last:
Alias:
   First:  Last:
Address 1:
Address 2:
Phone:
DOB:
   SSN:
Drivers License#:
Vehicle:
Spouse:
   First:  Last:
Child 1:
Child 2:
Physical Description:
 
Race:
Hair:
 
Sex:
Build:
 
Height:
Weight:
 
Other:
Employer Information:
Occupation:
Empolyer
Address:
Phone:
Fax:
Other Employment Info:
CC List:
3rd Party Info #1:
Video Copy Report Copy Invoice Copy
Address:
3rd Party Info #2:
Video Copy Report Copy Invoice Copy
Address:
3rd Party Info #3:
Video Copy Report Copy Invoice Copy
Address:

If you feel we can be of assistance, call us at the toll free number below

ATLAS AGENCY, INC.
PO Box 2146, Bangor, Maine. 04402
Tel: 800-258-7737   |   Fax: 800-660-2500