What if a policy number is missing?

Contact the previous carrier or ask the insured for a declarations page. If the carrier cannot be located, note the gap and flag the account for further verification to avoid underwriting errors.

Are carrier loss runs mandatory?

Carriers typically request loss runs for underwriting. Loss runs provide primary source verification; absence of carrier-issued loss runs increases the likelihood of follow-up and possible contingency conditions.

Can the report be e-signed?

Yes. Electronic signatures meet ESIGN (15 U.S.C. ch. 96) and UETA requirements when intent, consent, attribution, and retention are satisfied; for consumer-facing records include the ESIGN disclosure where required.

Is notarization required?

Notarization is generally not required for an Insurance History Report unless a state or carrier specifically requests a notarized attestation or power of attorney; verify with the receiving party.

How should PHI be handled?

Redact protected health information unless there is a HIPAA-compliant business associate agreement and a clear need; store any PHI under HIPAA safeguards and retain for six years under 45 CFR §164.530(j).

What if claim amounts differ between carrier and insured?

Record both figures, note the discrepancy, and attach carrier loss run PDF as the primary source. Route the matter for carrier confirmation to resolve reserve or payment differences.

Electronic Signature
Templates
Insurance
Insurance History Report

Insurance History Report

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Insurance History Report

Applicant / Insured Information

Insured Name DBA / Business Name (if applicable) Mailing Address

Phone

Email

Date of Birth / Formation Date

Entity Type (check all that apply)

Individual Corporation LLC Partnership Other:

Current Policy Details

Current Insurer

Policy Number

Policy Type

Coverage Limit(s)

Deductible

Annual Premium

Policy Period: From to . Policy issued in which state:

Prior Insurance History (Last 5 Years)

Provide prior carriers and policy details. If none, enter "None" in Insurer field.

Prior Carrier 1 - Insurer

Prior Carrier 2 - Insurer

Prior Carrier 3 - Insurer

Claims History

List all claims or losses in the last five years. Attach supporting documentation where available.

Claim 1 - Date of Loss

Open Closed

Claim 2 - Date of Loss

Open Closed

Claim 3 - Date of Loss

Open Closed

Coverage Selections / Coverage History

Indicate coverage types previously held or currently held. Check all that apply.

Liability Property Commercial Auto Workers' Compensation Professional Liability

Uninsured/Underinsured Motorist Medical Payments Comprehensive Other:

Exclusions / Material Limitations

The following are typical exclusions or limitations that may apply under the policies reported: intentional acts, punitive damages where excluded by statute or policy, fraudulent acts, liability arising from non‑disclosed operations, pollution or environmental impairment unless specifically endorsed, and losses subject to war, nuclear hazard, or other perils excluded by policy language. This report does not amend, waive, or alter any policy terms. Coverage is subject to the actual policy forms, endorsements, conditions, limitations and exclusions issued by each insurer.

I acknowledge that I have read and understand the exclusions and limitations described above.

Beneficiary / Loss Payee (If Applicable)

Provide beneficiary or loss payee information for life, property, or similar policies where applicable.

Beneficiary 1 - Name

Beneficiary 2 - Name

Documentation Checklist

Please indicate which of the following documents are attached to this report. Attach copies where available.

Loss run / claims history attached Declarations pages attached Photos or repair estimates attached

Police report(s) attached Certificates of insurance attached Other documents:

Declaration and Authorization

I certify that the information provided in this Insurance History Report is true, complete and correct to the best of my knowledge. I understand that material misrepresentation or omission of information may be grounds for denial of coverage or rescission of any policy issued in reliance on this report. I authorize any current or prior insurer, insurance-support organization, claims administrator, or their representatives to release to the requesting insurer or its authorized agents any loss information, claims history, underwriting files, or other relevant data necessary to evaluate coverage, underwriting, or claims handling. This authorization extends to records that may be considered confidential.

I further authorize the release of medical records, employment records, or other records to the extent necessary to verify a claim or loss where applicable. I understand that information obtained pursuant to this authorization will be used for underwriting, rating and claims-handling purposes and may be disclosed in accordance with applicable law.

I certify the foregoing and agree to the authorizations above.

Applicant Name:

Signature:

Date:

By signing above, the Applicant acknowledges the accuracy of the information supplied in this Insurance History Report and affirms authorization for the insurer to obtain and verify the information described in the Declaration and Authorization.

What an Insurance History Report Is and Why It Matters

An Insurance History Report is a consolidated record of an applicant's past and current insurance coverage, claims history, policy dates, carriers, and limits. Insurers, brokers, risk managers, and underwriters use this document to assess exposure, determine premiums, identify coverage gaps, and detect patterns of frequent claims. The report may draw from carrier-provided loss runs, prior policy declarations, and applicant disclosures. Accuracy and completeness affect underwriting decisions, bind authority, and regulatory reporting in regulated insurance markets.

Primary Purposes and Practical Benefits

The Insurance History Report summarizes prior coverage and claims to support risk assessment, premium setting, and renewal decisions while reducing underwriting time and improving consistency across accounts.

Who Typically Prepares and Reviews This Report

Different roles require different levels of detail: brokers need carrier contact and policy periods, underwriters need loss severity and frequency, and claims personnel need individual claim files and reserves.

Insurance brokers and agents who assemble prior carrier records and present risk profiles to markets.
Underwriters and risk management teams who evaluate claims patterns and coverage adequacy.
Claims analysts and loss control specialists who verify loss history and underwriting remediation.

Typical Signers and Their Roles

Broker — Account Manager

A broker/agent compiles the report from client disclosures and carrier loss runs, certifies accuracy, and submits it to underwriters. The broker must ensure carrier authorizations are current and that policy dates and limits match premium records.

Insured — Authorized Officer

An insured's authorized representative (owner, CFO, risk manager) attests to the accuracy of statements, provides signatures for confirmation, and supplies supporting documents such as declarations pages and claim abstracts when requested.

Core Elements to Include in a Professional Report

A complete Insurance History Report organizes coverage and claims information so reviewers can quickly evaluate exposure and gaps.

Policy Summary

Carrier name, policy number, effective and expiration dates, limits, deductibles, and endorsements presented in a concise table for each prior term.

Loss Run Summary

Itemized list of claims including date of loss, claim number, loss type, paid amounts, outstanding reserves, and status for each claim.

Claims Narrative

Short descriptions of significant losses, root causes, remediation steps taken, and whether any coverage disputes or subrogation actions occurred.

Exposure Notes

Key risk factors such as operations changes, new locations, subcontractor usage, regulatory exposures, or prior exclusions affecting coverage.

Supporting Documents

Attached declarations pages, loss run PDFs from carriers, litigation summaries, and any prior risk surveys or inspection reports referenced.

Certification

Signature block for the insured or authorized representative, date, and a brief attestation to the completeness and accuracy of disclosed information.

Step-by-Step: Preparing an Insurance History Report

Follow these standard steps to assemble, verify, and deliver a complete report to underwriters.

01

Collect Documents: Gather declarations pages, carrier loss runs, and claimant correspondence.
02

Populate Fields: Enter policy metadata, claims details, and exposures into the template.
03

Verify with Carriers: Confirm loss run figures and policy periods directly with carriers where possible.
04

Certify and Send: Have the authorized signer attest to accuracy and deliver the report to underwriters.

Customizing an Online Workflow for This Report

Configure a digital workflow to guide data entry, require attachments, and route the report for approvals.

Field	Configuration
Required Fields	Make policy numbers, effective dates, and claim totals mandatory.
Attachment Rules	Require carrier loss run PDF upload for each policy term.
Signer Order	Route to insured representative first, then to broker and underwriter.
Authentication	Use email link plus optional SMS code for signer identity verification.

Delivery and Integration Considerations

Ensure the chosen system provides audit trails, secure storage, and the ability to attach carrier-supplied PDFs for provenance.

File Formats: PDF | DOCX | XLSX supported
Integrations: Salesforce | NetSuite | Google Workspace
Authentication: Email link | SMS code | SSO

Typical Distribution and Submission Path

Reports move from data collection to verification, signature, and submission to underwriting or claims.

Prepare Report: Assemble policy and claims data into the template.
Verify Entries: Confirm with carriers or insured contacts.
Sign Electronically: Authorized officer signs and dates the report.
Submit to Underwriting: Deliver PDF and attachments to underwriter or upload to broker portal.

Required Data Elements at a Glance

Insured Name: Full legal name

Policy Period: Effective and expiration dates

Carrier: Insurer name

Policy Number: Exact policy ID

Coverage Line: Type and limit

Claim Totals: Paid and reserved

Common Risks and Consequences of Errors

Underwriting Delay: Incomplete data causes quote delays

Premium Mispricing: Missing claims can lead to incorrect pricing

Coverage Denial: Material omissions may result in dispute

Regulatory Exposure: False statements risk fines or sanctions

Contractual Breach: Misrepresentations may void coverage

Reputational Harm: Errors damage broker and carrier trust

Practical Tips for Accurate, Efficient Reports

Adopt consistent formats, require carrier documents, and use verification checkpoints to reduce errors and speed processing.

Standardize Date and Currency Formats

Use MM/DD/YYYY for dates and whole-dollar amounts for monetary fields. Consistency prevents misinterpretation across systems and reduces reconciliation issues.

Require Carrier Loss Runs

Attach carrier-issued loss runs whenever possible to provide source validation and minimize reliance on insured self-reporting; validated documents expedite underwriting reviews.

Use Clear Claim Status Labels

Label each claim as 'Closed — Paid', 'Open — Reserved', or 'Closed — No Payment' and include reserve amounts to clarify outstanding exposure.

Include Contact for Verification

Provide a named carrier or insured contact with phone and email to allow underwriters and auditors to resolve discrepancies without lengthy hold times.

Sample eSignature Pricing and Feature Comparison

Compare common vendor starting prices and core features relevant to signing Insurance History Reports; signNow is listed first per platform data.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies	Varies	Varies	Varies
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Industry Scenarios Demonstrating Typical Usage

Real-world examples show how reports shorten underwriting cycles and clarify prior loss exposure.

Optica Ventures — Underwriting Streamline

A mid-size broker consolidated carrier loss runs into a single report for each client to standardize submissions

The streamlined packet reduced follow-up requests
As a result, underwriters received complete files faster and quoting times shortened, improving placement speed for renewal accounts.

Fertility Centers of Illinois — Compliance

A healthcare provider attached redacted loss runs and declarations to meet insurer documentation requirements

HIPAA-compliant redaction and a clear signature block ensured privacy
The insurer completed risk assessment without additional information requests and documented compliance steps for audit trails.

Frequently Asked Questions and Troubleshooting

Answers to common questions about assembling, signing, and submitting an Insurance History Report.

Need help? Contact support

What if a policy number is missing?
Contact the previous carrier or ask the insured for a declarations page. If the carrier cannot be located, note the gap and flag the account for further verification to avoid underwriting errors.
Are carrier loss runs mandatory?
Carriers typically request loss runs for underwriting. Loss runs provide primary source verification; absence of carrier-issued loss runs increases the likelihood of follow-up and possible contingency conditions.
Can the report be e-signed?
Yes. Electronic signatures meet ESIGN (15 U.S.C. ch. 96) and UETA requirements when intent, consent, attribution, and retention are satisfied; for consumer-facing records include the ESIGN disclosure where required.
Is notarization required?
Notarization is generally not required for an Insurance History Report unless a state or carrier specifically requests a notarized attestation or power of attorney; verify with the receiving party.
How should PHI be handled?
Redact protected health information unless there is a HIPAA-compliant business associate agreement and a clear need; store any PHI under HIPAA safeguards and retain for six years under 45 CFR §164.530(j).
What if claim amounts differ between carrier and insured?
Record both figures, note the discrepancy, and attach carrier loss run PDF as the primary source. Route the matter for carrier confirmation to resolve reserve or payment differences.

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