To refer a case for investigation:

Contact our office at telephone number 03 8379 3600 and speak with one of our SureFact representatives to discuss your specific requirements.

Please find YOUR ORDER FORM HERE. Please either email it to admin@surefact.com.au or fax your referral to 03 8379 3699.

Request Services - Online Form

Please complete and submit the information below to request services or additional information

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 to submit your request. Thank you!

CUSTOMER INFORMATION
ALL CUSTOMERS
YOUR COMPANY:
FIRST NAME: *
LAST NAME: *
EMAIL: *
NEW CUSTOMERS
PHONE:
MOBILE:
ADDRESS:
CITY:
STATE:   POSTCODE:


CASE DETAILS
Case Type: *
State: *
Line of Business: *
Category: *
DATE OF LOSS / INJURY / DISABILITY: (DD/MM/YYYY)
SURVEILLANCE HOURS REQUIRED:
INSURED:
INSURED CONTACT:
CLAIM NO.
INVESTIGATION DUE DATE: (DD/MM/YYYY) *
INSTRUCTIONS: (reasons for investigation and instructions)
SPECIAL REQUESTS: (dates for surveillance, medicals etc.)
UPDATES REQUIRED:


SUBJECT DETAILS:

 
FIRST NAME:
LAST NAME:
ALIAS NICKNAME:
PHONE:
MOBILE:
ADDRESS:
CITY:
STATE:   POSTCODE:
DOB:
Drivers License #:
GENDER: Male Female
RACE:
HEIGHT:
WEIGHT:
BUILD:
HAIR:
MARITAL STATUS:
SPOUSE NAME:

CHILDREN NAMES & AGES:
ADDITIONAL DESCRIPTION:
INJURY:
EMPLOYER:
OCCUPATION:
REPRESENTED: YES    NO
LAW FIRM:
CLAIMS HISTORY
Receiving Benefits
Amount of Benefit
DESCRIPTION OF LOSS / ACCIDENT:
KNOWN VEHICLES:
(List Make, Model, Year)
VEHICLE 1

VEHICLE 2

VEHICLE 3
DOCTOR 1
DOCTOR 2
DOCTOR 3
PREVIOUS SURVEILLANCE
UPLOAD DOCUMENTS

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 if you are finished.

Please only press the SUBMIT button once and wait for the submission to process and you will receive a confirmation.
It may take up to 2 minutes for the case to be created and for us to display your case number and confirmation