Whitehall Bureau of Canada Limited

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*