Assign

Special Enforcement Bureau File #

Request Made By
	File / Claim #
	Company Name
	Address

	Name
	E-Mail
	Phone
	Fax

Criminal Civil Insurance BI GL WC Prop Other

Charge/Loss Date

Time

Location

Target / Subject

	Name
	Address

	Phone
	Date of Birth
	Sex	Male Female
	Social Security #
	DL#
	Occupation
	Description
	Injury / Damage

Defendant / Insured
	Name
	Address

	Phone
	Contact
	Witness #1
	Witness #2
	Witness #3

Case Description

Assignment / Instructions

Subject Attorney	CC Report

Phone	Phone

Billing Rate

Flat Rate Time & Expense Special Budget