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L&W
INVESTIGATIONS

Assign an Investigation — L&W Corporate Headquarters

Thank you for choosing L&W. We ask that you supply all requested information below but at minimum, you must enter your name and e-mail address. Upon successful submission, you will be redirected to a confirmation page. (If unable to submit this form for any reason, please e-mail us for assistance.)



Select: Activity Check Video Surveillance Other

Your name			Phone
Company			E-mail
Claim number

Insured			Phone
Address
City		State		Zip
Contact person			OK to contact insured?	Yes No

Subject		AKA
Address
City		State		Zip
Phone
Date of birth mm/dd/yyyy		Social Security number		Driver's license number
Photo available	Yes No
Physical description
Occupation		Subject's vehicles
Claimed injury			Date of injury mm/dd/yyyy
Physical Restrictions
Previous surveillance?	Yes No

Special instructions

Rev 2