Insurance Claims Circumstance Intake Form
Use this form to capture details about an insurance claim, incident, or circumstance, including status-specific financial information, narrative details, and signature information.
Claim / Incident / Circumstance Details
1) Is this a
*
Please Select
Claim
Incident
Circumstance
2) Name of Inspection firm
3) Name(s) of individual(s) of firm involved in claim/incident/circumstance
4) Name of Claimant
*
First Name
Last Name
5) Date of alleged claim/incident/circumstance
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
6) Date claim made (if applicable)
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
7) Name of Insurer (if applicable)
8) Present status of claim
*
Please Select
Pending
In Suit
Closed
9) Claim Number
Status-Based Financial Details
10) Total indemnity paid
11) Total expenses paid
12) Amount asked in summons
13) Claimant’s settlement demand
14) Defendant’s settlement offer
15) Insurer’s loss reserve
16) Expenses paid to date
Narrative and Preventive Actions
17) Detailed description of claim, incident, or circumstance
*
18) Allegations upon which the claim, incident, or circumstance is based
*
19) Actions taken to prevent a reoccurrence or similar claim, incident, or circumstance
*
Certification and Signature
Name (Owner, Partner or Senior Officer)
*
First Name
Last Name
Title
*
Date (Signature Date)
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: