Kidwell Investigations

Client Request / Case Assignment Form

Please use the form below to submit your case directly to Kidwell Investigations. I will respond directly by phone. If you need a response or documents via email or fax, indicate this below.
NOTE: The more information you can provide in your form the faster I will be able to expedite your case. The initial consultation is free.

Thank you

Company/Person Requesting Investigation/Surveillance

Client
Phone Number	Cell Phone
Address
City	State	Zip
Date	Claim #	* Insurance Companies
Email
Employer	Address
City	Phone
Date of Injury
Authorized Amount
Nature of Investigation:
Restrictions/Limitations,
Details of Who, What, When, Where, Why, How?

Claimant Information

Claimant's Name
Address
City		State	Zip
Home Phone Number
Cell Phone Number
Date of Birth
Approximate Age	* If DOB is unknown
Social Security Number
Height		Weight
Eyes		Hair
Race		Sex
Facial Hair		Glasses
Other distinguishable characteristics of Claimant

Places the Claimant may frequent and day(s) and time(s) that the Claimant is most likely to be in these places

Claimants Occupation

Occupation		Employer
Address		City
State		Zip
Phone

*Claimant's Additional or Previous Addresses*

Address		City
		State
Address		City
		State

Others Residing at Claimant's Residence

Name		Age
Relation
Name		Age
Relation
Name		Age
Relation
Name		Age
Relation

Nearby Relatives

Name	Age	Address
Relation
Name	Age	Address
Relation
Name	Age	Address
Relation

Associates of Claimant

Name	Age	Address
Name	Age	Address
Name	Age	Address

Claimant's Vehicles

Color		Make
Model		Year
Plate #
Color		Make
Model		Year
Plate #
Color		Make
Model		Year
Plate #

Medical Information

Doctor's Name	Address
City	State	Zip
Known upcoming appointments - Date	Time
Therapists Name	Address
City	State	Zip
Known upcoming appointments - Date	Time

Jan Kidwell - Licensed Iowa City Private Investigator

Kidwell Investigations