Contact us | Meridian Investigative Group, Inc

*Injury Description
Please describe the injury, including the body part(s) affected, type of injury, how it occurred, severity, and any treatment received to date.

Body Part(s) Affected (right shoulder, lower back, left knee, etc)
Type of Injury (strain, fracture, tear, contusion, laceration, etc.)
Cause of Injury (slip/fall, lifting, repetitive motion, impact, etc.)
Ongoing Treatment (physical therapy, Dr’s appointments)

Limitations
Please describe any limitations resulting from the injury (restrictions on lifting, standing, reaching, driving, or daily activities).

Physical Restrictions (e.g., no lifting over 10 lbs, limited standing/walking, restricted overhead reaching, limited bending/twisting)
Work Limitations (e.g., unable to type for more than 1 hour, cannot climb ladders, no prolonged driving)
Daily Living Impact (e.g., difficulty dressing, bathing, sleeping, caring for children, performing household chores)

ASSIGNMENT INFORMATION

Number of Days for Unmanned Surveillance

Specialty

Our Medical Canvas includes 3 specialties with 5 searches each; additional specialties may be added at an extra cost—if you have a specific facility, please note it in the comments

Crash report available?

Yes No

Would you like us to obtain a copy?

Yes No

Notes/Comments/Additional Services Needed

CLAIMANT INFORMATION

*Date of Birth MM/DD/YYYY

Social Security Number (SSN)

Other Known Names (Aliases)

PHYSICAL INFORMATION

Hair Color (Color, Length, Style)

Comments / Notes for Gender

Identifying Features (Tattoos, Scars, Glasses, Birthmarks, etc.)

*Is claimant represented

Yes No Unknown

Attorney Information

Does claimant have an upcoming medical appointment?

Yes No

Occupation / Employer

Hobbies & Activities (e.g., sports, gym, fishing, gardening)

Spouse / Dependents / Household Information (if relevant)

Known Social Media Links (Facebook, twitter(X), Instagram, Linkedin …)

VEHICLE INFORMATION

Year

Make

Model

Color

Tag #

State

Registered Owner

EMPLOYER INFORMATION / WORK STATUS

Contact Person's Name

Please Provide Claimant Work Schedule

Special Instructions or comments
Please include any special details investigators should know

Appointments, preferred surveillance times, gated community access, safety concerns… etc

Fraud Indicators
What red flags led you to suspect fraud?

Missed appointments, inconsistent medical reports, delayed reporting of injury active outside restrictions, prior claim history… etc

If you have supporting documents (ex: pictures of the subject, previous reports, first report of injury,photo ID etc) upload it below.

THIRD PARTY LIST

Video Invoice Report

First Name

Middle Name

Last Name

Address

City

State

Email Address

Phone Number

Relationship

Assign a Case

Contact

Email us at

Corporate address

Reach out at