Request Services - Online Form

Please complete and submit the information below to request services or additional information or click here for a printable version.

INSTRUCTIONS: To navigate from one blank to the next, please press the "Tab" button on your keyboard or use your mouse to click the appropriate box. When finished completing the form, check the box at the bottom of the page and click the "Submit" button or press the "Enter" button on your keyboard to submit your request. Thank you!

Services Requested:
Additional Services:
State:
Line of Business:
Select One: Please contact me with more information
Please provide price(s) for service(s) selected above
Please begin services selected above

Client Information:  
Your First Name  (Required):
Your Middle Name:
Your Last Name  (Required):
Your Title:
Company Name  (Required):
Address:
City:
State:   Zip:
Phone Number:
Fax Number:
Email Address  (Required):
Insurance Claim#  (Required):
Date Assigned:
Date Due:
Budget:
Has this case been previously investigated? Yes No
Defense Attorney:
Attorney Phone Number:
Hearing Date:


Claimant Information:

 
Claimant First Name:
Claimant Middle Name:
Claimant Last Name:
Social Security Number:
Date of Birth:
Address:
City:
State:   Zip:
Phone Number:
Email:
Screen Name:
Insured:
Address:
City, State, Zip:
Phone Number:
Claimant's Position:
Height:
Weight:
Race:
Gender: Male Female
Distinguishing Characteristics:
Marital Status:
Spouse's Name:
Spouse's Description:

Children Names/Ages (If there are more than the space below allows,
please enter in the additional comments box at the bottom of the form):
Child #1:   Age:
Child #2:   Age:
Child #3:   Age:

Claimant's Driver's License#:

Spouse's Driver's License#:
Known Vehicles:
(List Make, Model, Year)
Vehicle 1

Vehicle 2

Vehicle 3
Does the Claimant have a criminal or violent history?
Alleged Injury:
Restrictions:
Date of Injury  (Required):
Suspected Activities:
Claimant Attorney:
Address:
City, State, Zip:
Phone Number:
Attach Related Documents
Document Description:

Special Instructions/Additional Information:


Yes, I have reviewed the information I am submitting and it is accurate to the best of my knowledge


Thank you for taking the time to complete this form. Please click the "Submit" button once if you are finished.

IMPORTANT: It may take 10-20 seconds for your request to process. Please DO NOT click the "Submit" button more than one time. Once your order has been processed, you will be redirected to a confirmation page with your Titan File Number. If you have any questions or problems with your submission, please contact us at (866) 964-0930 ext. 114.