Tahl & Associates, LLC
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Investigation Request

Date:
Insured's Name:
Date of Birth:
Social Security #:
Date of death/disab:
Claim #:
Policy #:
Residence Address: (use box below)
Residence Phone:
Beneficiary Name:
Beneficiary Phone:
Beneficiary Address:
Relationship to insured: (use box below)

Requestor:

Company Name:

Telephone:

Fax:

Email:

Type of case: (check)
Contestable Life
Waiver of Premium
Continuance of Disability
ADB
Other

Smoker/Tobacco issued:

Yes

No

N/A

Application Date:

General Instructions:

	Personal Interview
	Telephone Interview
	Secure Provider Records for the Period From		through
	Secure Pharmacy Profile
	Pursue all Leads
	Secure Coroner/ME Report
	Secure Police Investigation/Incident Report
	Obtain Driver Abstract
	Secure Signed Authorizations
	Secure Signed Confirmation of Interview Statement

Documents Provided: (check all that apply)

	Death Certificate		Signed Authorization		Other (describe below)
	Application		Claim Proofs

via Email

via Fax

Admitted Information on the Application is as Follows:

Additional/Special Instructions:

Thank you

Your investigation request has been sent!

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