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[null,"PRIVATE INVESTIGATION ASSIGNMENT FORM"]
[]
[]
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[null,"Special Instructions/Assignment:"]
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[null,"CLIENT"]
[null,null,"Company Name & Address"]
[null,null,"Contact & Telephone #",{"$nulls":8},"Fax #"]
[null,null,"File/Claim #",{"$nulls":7},"E-Mail"]
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[null,"CLAIMANT"]
[null,null,"Full Name",{"$nulls":8},"D.O.B."]
[null,null,"Last Known Address"]
[null,null,"Telephone #",{"$nulls":7},"Cell #"]
[null,null,"SS#",{"$nulls":7},"Drivers License #"]
[null,null,"Sex",{"$nulls":4},"Race",null,"Marital Status",null,"Spouse's Name"]
[null,null,"Physical Description"]
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[null,null,"Occupation",{"$nulls":7},"Phys. Limitations"]
[null,null,"Claimant's Vehicle & Tag #'s"]
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[null,null,"Current Employer's Name & Address"]
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[null,null,"Injury Description"]
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[null,null,"Next Appointment",{"$nulls":7},"Date of Injury"]
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[null,null,"Claimant's Attorney Name & Address"]
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[null,null,"Completed by",{"$nulls":7},"Date"]
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[null,"Multi-Line Adjustments & Private Investigations"]
[null,"License # A09879"]
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[null,"                    Telephone # 713-973-1901",{"$nulls":7},"       1462 Campbell Road ",null,"                                      Fax # 713-467-1991      "]
[{"$nulls":9},"    Suite 125 "]
[null,null,"                                                          Houston, Texas 77055-4600 "]

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