Florida licensed private investigators providing professional, confidential investigative services and camera Surveillance services which includes infidelity, adultery cheating spouses the unfaithful and affairs on TV throughout Florida and nationwide on cases originating within the state of Florida. A JP Merlano Florida Private Detective Agency Lic# A-2300209 Member of FALI, NAIS, ACFE
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Cheaters on TV A WildCard
Investigations Company

Founder
JP Merlano

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561-577-7715
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REQUESTOR:

COMPANY/FIRM:


CITY: State:

IF NEW REQUESTOR, INCLUDE STREET ADDRESS:

EMAIL:
PHONE:
CLIENT FILE NO :

TYPE OF CLAIM WORKERS’ COMPENSATION    LIABILITY/DISABILITY    OTHER

CLAIMANT/SUBJECT LAST NAME:
FIRST NAME:
MIDDLE NAME:
 

LAST KNOWN STREET ADDRESS: CITY:

STATE: ZIP:

ALTERNATE STREET ADDRESS: CITY:

STATE: ZIP:

PRIMARY PHONE: (include area code)
SECONDARY PHONE:
AGE:
DOB: (mm/DT/YR)
SSN:
RACE:

SEX: M      F
HEIGHT: ’  "
WEIGHT:
BUILD:
HAIR COLOR:

HAIR LENGTH: S    S/L      L

OTHER PHYSICAL CHARACTERISTICS:
 

MARITAL STATUS:

SINGLE MARRIED DIVORCED WIDOWED
SPOUSE’S NAME:
# OF DEPENDENTS:
KNOWN VEHICLES:
 

DRIVERS’ LICENSE #:

STATE:

DATE OF INJURY:

TYPE OF INJURY(IES):

JOB DESC:

ACCIDENT DESCRIPTION:

PHYSICIAN/ATTORNEY/MRI/IME APPOINTMENT DATE:
TIME:
LOCATION:
PHYSICIAN NAME & ADDRESS:
PHONE: (include area code)

IS THE CLAIMANT IN PHYSICAL THERAPY?

Y    N

WHERE?

PHONE:
(include area code)

 

RECEIVING BENEFITS?

Y     N

HOW? PICK UP MAILED TO PROVIDED

ADDRESS:

OTHER ADDRESS:

 

IS SUBJECT REPRESENTED?

Y    N

ATTORNEY’S NAME:
FIRM NAME:
DEFENSE ATTORNEY:
FIRM NAME:
PHONE:

ADDRESS:

INSURED COMPANY NAME:
INSURED CONTACT NAME:
INSURED STREET ADDRESS:
CITY:
STATE:
ZIP:
INSURED CONTACT PHONE: (include area code)
SERVICE(S) DESIRED:
DUE DATE:
NUMBER OF: SURVEILLANCE DAYS

OBJECTIVE/SCHEDULING PREFERENCES:

SPECIAL INSTRUCTIONS:

 

 

 

 

 
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Public Inquiries (561) 577-7715 || Intake Operator : (561) 459-6904 || FL Agency Lic# A-2300209
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Cheaters on TV

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