MIG - Online Case Intake

Please fill in the series of case questions listed below. Once you have completed the questions and the case is submitted, you will be supplied a username and password to our sytem within 8hrs to manage your case.

Today's Date * / MM / DD YYYY
Case Requester * First Last
Company
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Email *
Phone * - (###) - ### ####
Fax - (###) - ### ####
Type of Claim?
Date of Loss / MM / DD YYYY
Claim #
Requester Case #
Has this case been worked before? * Yes No I don't know
Claimant * First Last
Claimant Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Claimant Phone - (###) - ### ####
Claimant DOB
Claimant SSN
Claimant Driver's License #
Race
Gender Male Female
Height
Weight
Hair Color
Marital Status
Spouse Name First Last
Claimant special physical characteristics (Scars & Marks)
Occupation
Alledged Injury
Restrictions
Children/Other Co-Habitants & Ages
vehicle 1 (Make & Model)
Vehicle 1 Tag #
Vehicle 2 ( Make & Model)
Vehicle 2 Tag #
Rehabilitation Center
Rehabilitation Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Rehabilitation Phone - (###) - ### ####
Attorney Name Title First Last Suffix
Attorney Firm Name
Attorney Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Attorney Phone - (###) - ### ####
Employer
Employer Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Employer Phone - (###) - ### ####
Physician Name Title First Last Suffix
Physician Office Name
Physician Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Physician Phone - (###) - ### ####
Wage Loss Paid? Yes No I don't know
Weekly Amount Paid $ . Dollars Cents
Any upcoming appointments and or hearings?
Days of Surveillance Requested
Surveillance day requested Standard 8hrs / day Standard 4hrs / day
Surveillance day request (Other)
Report Delivery Email Hard Copy Both
Report Format PDF MS Word
Video Delivery Email - Reduced resolution/quality Hard Copy - Hi Def DVD Both
Video Delivery Format DVD CD-Rom
Case Due Date / MM / DD YYYY
Case Comments
Upload File #1
Upload File #2
Upload File #3