The Hallahan Group Inc.
Phone: 516-208-5476  |  Fax: 718-535-7663
New Case Referral for Investigation or Surveillance
New Case Referral Online Form for Investigation or Surveillance
Contact:
Carrier
Contact Person
Address
Email
* required
Phone
Claim #
Date of Loss
Claimant Information:
(if your referral sheet contains all this information, skip this portion and upload below)
Claimant's Name
Address
SSN last 4
Date of Birth
Home Phone
Cell Phone
Description
DMV Information
Employer
Occupation
Injury/Physical Limitations
Assignment:
Assignment
Deadline
Instruction
Surveillance assignments please specify
Budget

Please specify either monetary or hourly limit.
IME, EUO, EBT, Court Appearances.
Upload Documents:
(You may upload your assignment sheet or additional documentation)
Select A Document

For multiple files, please combine them into a .zip file before uploading.