Name: FULLCIRCLE INVESTIGATIONS INC
Price range: $$$

Submittal Forms

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FullCircle Investigations Inc.

New Mexico License #
PI 2023-0901 | 2023-0894

California License # PI 188905
Kansas License # D-6169

145 Calle Del Presidente,
Unit# 5332,

Bernalillo, NM 87004

63 Via Pico PLZ, #116
San Clemente, CA 92672

Office: (949) 325-9099
Toll Free: (844) 883-3033
Fax: (949) 298-2322
Email: [email protected]

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Form 3 | Workers Comp or Fraud Investigation

Contact Our Team to Get Started!

To Be Filled Out By Responsible Representative
Request Date*
MM slash DD slash YYYY
Your Name (Requester)*
First Last
Company (when required)
Address
Street Address Address Line 2 City State ZIP Code
Email*
Phone #*
Claim Type
Claim #
Budget / Days / $*
Date of Loss
MM slash DD slash YYYY
Date Requested to Complete By
MM slash DD slash YYYY
Prior Investigations
CLAIMENT INFORMATION
Required Fields marked with asterisk (*)
Name*
First Middle Last Suffix
Nickname (when known)
Address*
Street Address Address Line 2 City State ZIP Code
Phone
Cell Phone
Social Security #
Date of Birth
Age (years)
Sex*
Race
Marital Status
Spouse / Significant Other Name (if applicable)
First Middle Last
Height (feet and inches)
Weight (pounds)
Driver's License #
Driver's License State
Features
- Glasses
- Tattoos
- Mustache
- Beard
- Goatee
- Jewelry
- Clothing/hats/caps etc
Feature Details
Injuries
Restrictions
Children and ages
Employer
Employer Contact Person
Employer Phone
Vehicle Information (color, make, year, license plate #/state)
Known Activities
Scheduled PT / Appointments / Times / Locations

Click on the + to the right for additional schedules input.
Claimants Attorney Firm Name
Claimants Attorney Firm Address
Street Address Address Line 2 City State ZIP Code
Additional Information / Comments
File upload if required
Max. file size: 100 MB.
Consent Request Terms & Conditions*
Read Before Accepting.
By checking this box, the REQUESTOR herein referred to as (CLIENT) attests that he/she has not misrepresented him/herself, their company, organization, or purpose for requesting the services that AGENCY provides, and appoints and authorizes Fullcircle Investigations Inc as its AGENT to conduct the requested investigation. AGENCY will contact CLIENT prior to beginning case work for verification, billing, and reporting. The information herein is for the sole use of the CLIENT who is responsible to safeguard the information provided from unauthorized third-party disclosure as defined by the Gramm-Leach-Bliley Act (GLBA), Fair Credit Reporting Act (FCRA), Fair and Accurate Credit Transactions Act (FACTA), Drivers Privacy Protection Act (DPPA) and Right to Financial Privacy Act (RFPA), and applicable state and federal laws and regulations. It is incumbent upon the CLIENT and his/her representatives to be fully knowledgeable about such laws and regulations and/or seek legal counsel prior to dissemination of reported information. CLIENT agrees to hold all information provided in strict confidence, except as allowed by federal or state law. Furthermore, the CLIENT affirms the information requested and/or learned during the investigation is not to be used for harassment, stalking, intimidation, threatening or any other illegal purpose(s). CLIENT agrees to indemnify and hold harmless Fullcircle Investigations from any damages arising out of any improper use of this information, and the information is furnished in reliance on that indemnity. AGENCY will keep its findings strictly confidential and will not disseminate or release any findings to third parties unless authorized IN WRITING by the CLIENT or ordered by court.
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Email
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Unsure which form to use or have questions, choose Form 1

Form 3 | Workers Comp or Fraud Investigation

To Be Filled Out By Responsible Representative

CLAIMENT INFORMATION