REFER A CASE

Please call us at (800) 362-0169 to discuss the requirements of your case.

California Claims Solutions
P.O. Box 1735
Soquel, CA 95073

(800) 362-0169
(800) 362-0334 (fax)

Please fill out the Referral Form then select the Submit button. If we receive the Referral Form during business hours we will respond within the same business day otherwise, we will contact you during the next business day.

If you have any questions or need help filling out the form please call us at (800) 362-0169.

CASE NUMBER:

(For CCS internal use only)

*Date:
Due Date:
Time Authorized for Sub Rosa:
Specific Days for Sub Rosa to be Run:
Cap:
Quote:
Retainer:
Referral taken by (for office use only):
Applicant represented:

Sub Rosa:
Activity Check:
AOE/COE:
Subrogation:
Recorded Statement(s):
Records:
Records Review:
Background Check:
Locate:
Asset Check:
Locate and Serve:
Other:

*Additional instructions may be given in the fields above or in the Special Instructions section at the bottom of this form.

*
claimnant
subject
*Claimant or Subject name:
*Address:
*City/State/Zip:
Phone (if available):
Cell:
AKA:
Prior Address:
Known Vehicles:

Client Company (if applicable):
Address:
City/State/Zip:
*Adjustor/Contact:
Job Title (if applicable):
Phone:
Cell:
Email:
Send Film in Following Format:

*SSN:
*DOB:
DOH:
*DOI:
NOI:
Occupation:
*Injury:
Claim # (if available):

Defense Attorney:
Firm:
Street:
City/State/Zip:
Phone:
Email:
Mail to:
Address only:
Send Film in Following Format:

Gender:
Height:
Weight:
Build:
Hair:
Eyes:
Race:
Beard/moustache:
Glasses:
Other:

*Employer:
Street:
City:
*Contact Person:
*OK to contact?:
*Phone Number:
Job site:
Currently Working?:
cc via email to:

Previously Investigated?:
Aware?:

*What Happened?:
Restrictions:
*Special Instructions:
Information for Medical or Legal Pickup:

Attachment #1:
Attachment #2:
Attachment #3:
Attachment #4:
Attachment #5:

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