Insurance Claim Investigation Questionnaire

I. Claim & Policy Information

Claim Number

Date Claim Reported

Policy Number

Policy Holder Name

Policy Holder Contact

Phone

Email

Type of Loss

Date of Loss

Time of Loss

Location of Loss

Street Address

City

State/Province

Zip/Postal Code

Insured's Deductible/Excess

II. Claimant/Injured Party Information

Note: This section applies if the claimant is not the policyholder (e.g., a third-party liability claim).

Claimant Name

Claimant Contact

Phone

Email

Claimant Address

Street Address

City

State/Province

Zip/Postal Code

Relationship to Policy Holder

Nature of Injury/Damage Claimed

Has a Demand Letter been received?

Yes

No

III. Incident Details - Narrative & Facts

A. Narrative of the Loss

Describe in detail how the loss/incident occurred.

What was the specific cause of the loss? (e.g., Fire, Theft, Collision, Slip and Fall, Storm, Equipment failure, etc.)

Who was present at the time of the incident? (List names and their role/relationship.)

	Name	Role/Relationship
	A	B
1
2
3
4
5

Was the incident reported to any authorities (Police/Fire Dept.)?

Yes

No

If Yes, Agency Name:

Report/Case Number:

Date Reported:

B. Property/Vehicle/Injury Specifics

For Property:

Was the property owned, rented, or leased?

owned

rented

leased

What is the estimated age/condition of the damaged property?

Was any temporary repair or mitigation action taken?

Yes

No

For Vehicle (Auto/Marine):

Make, Model, Year of involved vehicle

Vehicle Identification Number/Hull Number

Was the vehicle drivable after the incident?

Yes

No

For Injury/Bodily Harm:

Was medical attention immediately sought?

Yes

No

Name of initial treatment facility/doctor

Date of initial treatment:

Is the claimant currently restricted from work/activity?

Yes

No

IV. Investigation Procedures

When was the Initial Contact with Policy Holder

Please describe in detail the findings or observations.

When was the Site/Scene Inspection

Please describe in detail the findings or observations.

Were photographs or video taken?

Yes

No

Please describe in detail what was captured.

Were witness interviews conducted?

Yes

No

List names/contact info of witnesses

	Name	Phone	Email
	A	B	C
1
2
3
4
5

How were the statements taken?

Recorded

Written

Other:

Indicate who provided the statements.

What official reports were obtained?

Police

Fire

Weather

Other:

List report numbers obtained.

When was the policy coverage reviewed?

Were the external experts or adjusters engaged?

Yes

No

List firm or individual name and purpose.

V. Witness Information

	Name	Contact Number	Relationship to Incident	Statement Taken?
	A	B	C	D
1
2
3
4
5

VI. Adjuster/Investigator Assessment

Is coverage applicable based on initial review?

Yes

No

Undetermined

If No, specify the likely policy exclusion:

Are there any indicators of potential fraud, misrepresentation, or moral hazard?

Yes

No

If Yes, explain the concern:

What is the preliminary estimate of the total loss/claim value?

Are there any other insurance policies/parties that may cover this loss (Subrogation/Contribution potential)?

Yes

No

If Yes, specify the party:

VII. Certification

Investigator Signature