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Whitehall Bureau of Canada Limited
request form
Please complete the following  to request an investigation. This form may also be printed upon completion and sent by fax.
Any problems with this form please email - webmaster@whitehallcanada.com
Fields with an * must be completed.
Type of Request:
  Insurance    Corporate    Legal    Other
contact information
* Date of Request:
* Company:
* Contact:
* Telephone #
* Fax #:
* Email Address:
* CLAIM NUMBER:
* INSURED:
 
 
subject information
* Subject Name:
Birthdate:
  Primary Address:
SIN #:

Secondary Address:

Gender:
Telephone #:
Subject Description:
Cell/Mobile #:
Driver's License #:

Vehicle (Make/Model):

Plate:

 
 

employer information

Employer :
Address :
Telephone # :
Occupation :
Comments/
Remarks:
 
 
claim information 

*Date of Loss/Claim : 

*Type of Loss :
*Declared Disability:
1st or 3rd Party :
P/C#  :
Adjuster:
Contact #  :
Nature of Claim:
 
 
other contact information

Lawyer :

Address :
 Family Physican :
Address :
Physiotherapist :
Address :
Chiropractor: :
Address :

Other :

Address :
Known Appointments:
 
 
type of investigation
Surveillance         Background       Statement        Undercover      Other
Specific Dates:
Specific Times:
Mediation Date:
Arbitration Date: 
Discovery Date: 
Report Due Date: 
*Budget:
Comments/Instructions:
Call To Discuss Assignment

 

 

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