a DCI Holdings Inc. company

Document Retrieval & Duplication via Authorization Form

Fields marked with "*" are required fields.

Customer/Billing Information:
Ordering Party:
*First Name: *Last Name:
*E-mail:    
Type of Service: Send Invoice to:
*Firm Name: Carrier Name:
*Attorney's Name: Adjuster's Name:
Address: Address:
City: City:
State: State:
Zip Code: Zip Code:
*Phone - Ext:   Phone:
Fax: Fax:
Firm File #: Name of Insured:
Date for Express Service (mm/dd/yy) Claim File #:
Date of Loss: (mm/dd/yy)    

Record's Subject:
Please enter NA for any data not available.
Subject's Name: A.K.A.:
Date of Birth: (mm/dd/yy) Soc. Sec. #:
Number of Copies: X-ray Fee Limit:
Delivery Instructions:
Number of Copies to Each Recipient
Your Firm   Carrier   Other 		If you entered an amount for other,
indicate to whom, with address:

Record Locations:
 In Depth Research OK If Required
Name: Record Type(s):
Press & HOLD the "Ctrl" button to select more than one


Special Instructions:
Address:
City:
State:
Zip:
Phone:
Residence   Business
 
Name: Record Type(s):
Press & HOLD the "Ctrl" button to select more than one


Special Instructions:
Address:
City:
State:
Zip:
Phone:
Residence   Business
 
Add Additional Record Locations

PLEASE BE SURE TO FAX US THE SIGNED AUTHORIZATION AT 888-496-9423.
If you don't have a signed authorization, DCI can obtain one from the Subject.
Approve DCI to Obtain Authorization: Yes     No
  Name:
  Address:
  City:
  State:
  Zip:
  Home Phone:
  Work Phone:

If you would like to speak to a representative, please call DCI Legal Photocopy Services at 888-457-4426.
 














































Add Additional Record Locations:
Name: Record Type(s):
Press & HOLD the "Ctrl" button to select more than one


Special Instructions:
Address:
City:
State:
Zip:
Phone:
Residence   Business
Back to Main Form: Record Locations or enter Additional Records Below
 
Name: Record Type(s):
Press & HOLD the "Ctrl" button to select more than one


Special Instructions:
Address:
City:
State:
Zip:
Phone:
Residence   Business
Back to Main Form: Record Locations or enter Additional Records Below
 
Name: Record Type(s):
Press & HOLD the "Ctrl" button to select more than one


Special Instructions:
Address:
City:
State:
Zip:
Phone:
Residence   Business
Back to Main Form: Record Locations or enter Additional Records Below
 
Name: Record Type(s):
Press & HOLD the "Ctrl" button to select more than one


Special Instructions:
Address:
City:
State:
Zip:
Phone:
Residence   Business
Back to Main Form: Record Locations or enter Additional Records Below
 
Name: Record Type(s):
Press & HOLD the "Ctrl" button to select more than one


Special Instructions:
Address:
City:
State:
Zip:
Phone:
Residence   Business
Back to Main Form: Record Locations or enter Additional Records Below
 
Name: Record Type(s):
Press & HOLD the "Ctrl" button to select more than one


Special Instructions:
Address:
City:
State:
Zip:
Phone:
Residence   Business
Back to Main Form: Record Locations



Copyright © DCI Holdings, Inc., All rights reserved
Legal Statement : Privacy Statement