Witness Order Form

All Witness Statement and Scene Investigation Assignments cannot be started until we receive a copy of the police report by fax (954) 797-9418 or PDF. by email jeremy@shannoninvestigationsinc.com.

Witness Statement / Scene Inv. Order Form
Agency License #: A-98-00005
Form Type:
Claim Rep:
Claim #:
Insured:
Return To (if surveillance needs to be sent to defense counsel enter attorney name here)
Subject:
Address:
City:
State:
Zip:
Phone:
Any Additional Information On Subject:
Is a scene investigation needed?: YesNo
Are photos of damaged property needed?: YesNo
What specific facts or questions need to be asked with the witness? :
Client's Comments To Investigator:
Rush Assignment: YesNo
There is an additional $200 rush charge for all assignments that must be started within 1 week.
Your Contact Information
First Name:
Last Name:
Company Name:
Address Line1:
Address Line2:
City:
State:
Zip Code:
Country:
Preferred Phone #:
Secondary Phone #:
Email Address:
Defense Counsel and or Adjuster Contact Information
First Name:
Last Name:
Company Name:
Address Line1:
Address Line2:
City:
State:
Zip Code:
Country:
Preferred Phone #:
Secondary Phone #:
Email Address: