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CS CONSULTING SERVICES, LLC

SERVICE REQUEST FORM


CLIENT INFORMATION

Date ____________________________________________
     Your Claim #  _______________________________
Requestor _______________________________________
     Employer __________________________________
________________________________________________
     ___________________________________________
________________________________________________
     ___________________________________________
     TYPE OF CLAIM:
Telephone _______________________________________
     O  Workers' Compensation
FAX ____________________________________________
     O  Liability
     O  Other
CLAIMANT/SUBJECT

Name __________________________________________________________________________________________________
                                                  (First)                                                                                                 (Middle)                                                                                                   (Last)
Address ________________________________________________________________________________________________
                                                          (Number)                                (Strret Name)                                                                                 (City & State)                                         (Zip Code)

Telephone Number (_________)_____________________________________________________________________________
Date of Birth ____________________________________________________________________________________________
Social Security Number ___________________________________________________________________________________
Physical Description:   Height __________     Weight ____________    Hair Color _____________    Eye Color ____________
Other Physical Characteristics _____________________________________________________________________________
________________________________________________________________________________________________________
Date of Loss/Injury _______________________________________________________________________________________
Nature of Loss/Injury ______________________________________________________________________________________
________________________________________________________________________________________________________
Subject's Job Duties ______________________________________________________________________________________
________________________________________________________________________________________________________

SERVICES REQUESTED (Check all that apply)

O  Locate
O  Surveillance
O  Activities
O  Record Search
O  Recorded Statements
O  Written Statements
O  Alive & Well
O  Trial Testimony
O  Other (describe below)
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

Please FAX this completed form to:  (248) 682-9468     (OR) MAIL TO:
 CS Consulting Services, 6632 Telegraph Road #329, Bloomfield Hills, MI 48301-3012