Claim Number
Date Claim Reported
Policy Number
Policy Holder Name
Phone
Type of Loss
Date of Loss
Time of Loss
Street Address
City
State/Province
Zip/Postal Code
Insured's Deductible/Excess
Note: This section applies if the claimant is not the policyholder (e.g., a third-party liability claim).
Claimant Name
Phone
Street Address
City
State/Province
Zip/Postal Code
Relationship to Policy Holder
Nature of Injury/Damage Claimed
Has a Demand Letter been received?
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 | ||
|---|---|---|---|
1 | |||
2 | |||
3 | |||
4 | |||
5 |
Was the incident reported to any authorities (Police/Fire Dept.)?
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?
For Vehicle (Auto/Marine):
Make, Model, Year of involved vehicle
Vehicle Identification Number/Hull Number
Was the vehicle drivable after the incident?
For Injury/Bodily Harm:
Was medical attention immediately sought?
Is the claimant currently restricted from work/activity?
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?
Were witness interviews conducted?
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?
Name | Contact Number | Relationship to Incident | Statement Taken? | ||
|---|---|---|---|---|---|
1 | |||||
2 | |||||
3 | |||||
4 | |||||
5 |
Is coverage applicable based on initial review?
Yes
No
Undetermined
Are there any indicators of potential fraud, misrepresentation, or moral hazard?
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)?
Recommended Next Steps for Resolution:
further interviews
appraisal
request medical records
deny claim
pay claim
Other:
Investigator Signature