What is this form used for?

The form summarizes prior claims and losses to assist underwriting, premium setting, and claims evaluation. Insurers use it to detect patterns, assess residual risk, and decide coverage terms for new or renewing policies.

Who must sign the form?

An authorized representative of the insured or the named insured typically signs. Agents may attest to received documents but signatures should come from an authorized officer or individual with binding authority.

Can the form be e-signed?

Yes. Electronic signatures are legally valid under ESIGN (15 U.S.C. ch. 96) and UETA in most states, provided intent, consent, attribution, and retention requirements are met for the transaction.

What if data is missing or incorrect?

Missing or inaccurate entries can cause underwriting delays, increased premium, or claim denial. Correct errors promptly and provide supporting documentation to the requesting carrier to avoid adverse action.

How long does processing take?

Processing varies by carrier and complexity; simple verifications often take 7–14 business days, while complex loss reviews or litigation-related claims may take substantially longer.

Are notarization or witnesses required?

Not usually required for routine loss histories, but sworn affidavits or certain state forms may demand notarization or witnesses. Check state-specific rules before execution for legally sensitive statements.

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Insurance Loss History Form

Insurance Loss History Form

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INSURANCE LOSS HISTORY FORM

WHEREAS, the Requesting Party requires a verified loss history for underwriting, audit, or risk management purposes; and

WHEREAS, the Insured is authorized under the policy and applicable law to request or disclose claim and loss information to the Requesting Party, subject to the terms of this form and any applicable confidentiality protections; and

WHEREAS, the Insurer and Requesting Party acknowledge that the information provided herein will be relied upon for underwriting, pricing, or claims settlement decisions and warrants that the responses are true, complete, and made in good faith.

Requesting Party Information

Requesting Party Name Contact Person Contact Address Phone / Email

Insured / Policy Information

Insured / Named Insured Policy Number

Insurer / Carrier

Policy Effective Date

Policy Expiration Date

Scope of Loss History Request

Provide a complete loss history for the Insured for the period indicated below. The Requesting Party seeks verified claim information including dates of loss, nature of loss, amounts paid, reserves, and claim disposition. The Insurer and Insured agree to the scope and limitations set forth herein.

Loss History Period (From) Loss History Period (To) Narrative Description of Scope or Special Instructions

Loss Details (Provide each loss known to Insured)

For each claim/loss, provide the following details. If additional space is needed, attach supplemental pages and indicate number of pages attached below.

Claim Date Claim Number

Cause / Type of Loss

Amount Paid

Outstanding Reserve

Loss Location Brief Description Open Claim Closed Claim

Claim Date Claim Number

Cause / Type of Loss

Amount Paid

Outstanding Reserve

Loss Location Brief Description Open Claim Closed Claim

If additional losses exist beyond those listed above, indicate the total number of attached supplemental pages and include the same fields for each attached loss.

Number of Supplemental Attachment Pages

Fees and Payment (If Applicable)

The Requesting Party agrees to pay reasonable administrative or retrieving fees charged by the Insurer for compiling and delivering certified loss runs, subject to the Insurer's written fee schedule. Payment is due in accordance with the schedule below.

Fee Amount Payment Due (Days) Late Fee / Interest

Authorization, Confidentiality, and Term

The Insured hereby authorizes the Insurer to disclose loss history information to the Requesting Party for the specified purpose. All disclosed information shall be treated as confidential by the Requesting Party and used only for underwriting, risk transfer, or transactional purposes unless otherwise required by law. The Requesting Party shall not disclose or redistribute the data except to its agents or advisors who have a need to know and who are bound by similar confidentiality obligations.

Authorization Term: This authorization becomes effective on the date signed by the Insured and remains in force until , unless earlier revoked in writing with days' prior written notice to the Insurer.

Governing Law; Entire Agreement

This form and any disclosure made pursuant to it shall be governed by the substantive law of the jurisdiction selected by the Insurer's principal place of business unless otherwise agreed in writing. This form contains the entire agreement between the parties regarding the release and use of the requested loss history information and supersedes any prior oral or written agreements on the same subject.

Certifications and Acknowledgments

By signing below, the Insured certifies that the information provided in this form is true and complete to the best of the Insured's knowledge. The Requesting Party acknowledges that it will rely upon the accuracy and completeness of disclosed loss history and accepts responsibility for unauthorized use or disclosure.

Additional Comments or Instructions

Attachments

Certified loss runs attached Claim notes or reserves documentation attached

Insured / Policyholder:

By:

Date:

Requesting Party / Authorized Representative:

By:

Date:

What the Insurance Loss History Form Is

The Insurance Loss History Form is a standardized record used by insurers, agents, and risk managers to document a policyholder's prior claims, losses, and loss-adjustment activity. It includes event dates, causes, amounts paid, reserves, and claim status so underwriters can assess exposure, verify prior coverage, and price risk. The form is typically requested at application, renewal, or when coverage changes. Complete and accurate entries reduce follow-up requests, support consistency across carriers, and create an auditable paper or electronic trail for underwriting and claims decisions.

Why a Complete Loss History Matters

A complete Insurance Loss History Form gives underwriters reliable evidence of prior losses, helping set appropriate premiums, identify fraud indicators, and avoid coverage gaps. Accurate histories reduce manual verification, speed decision-making, and create defensible records useful in audits, reinsurer reviews, and claim disputes.

Who Interacts with This Form

Several roles rely on the Insurance Loss History Form during underwriting, claims handling, and risk analysis.

Insurance agents gather loss histories during new business submissions and renewals to support accurate underwriting.
Claims adjusters verify past payments, reserves, and recoveries to determine subrogation potential and current claim handling.
Policyholders or their representatives provide documentation and corrections to ensure underwriting records reflect factual loss history.

Core Elements a Professional Form Should Include

A well-structured Insurance Loss History Form balances completeness with usability to support underwriting, claims analysis, and regulatory recordkeeping.

Claim Summary

List each loss with claim number, event date, location, cause, and a concise narrative. Cross-reference policy number and indicate open or closed status for underwriting clarity and trend analysis.

Financial Details

Provide amounts paid to date, current reserves, recoveries, and deductible application. Break down payments by type when possible to support accurate premium modeling and loss-severity calculations.

Supporting Documents

Attach or link police reports, adjuster findings, repair invoices, photos, and legal filings. Clear documentation reduces verification time and strengthens claim defensibility during audits.

Coverages Affected

Specify which policy sections applied (for example property, liability, auto, flood), limits, and endorsements invoked. Note exclusions that affected coverage decisions to inform future underwriting.

Third-Party Contacts

List other insurers, claimants, vendors, and subrogation contacts with policy numbers and claim IDs to aid recovery efforts and multi-carrier coordination.

Status & Notes

Record current status, settlement offers, litigation holds, and internal notes. Flag potential fraud indicators or coverage disputes for expedited specialty-unit review.

Step-by-Step: Completing the Form Correctly

Complete the form in the sequence below to ensure consistent entries and avoid omissions that trigger manual follow-up.

01

Gather Records: Collect police reports and invoices.
02

Fill Identifiers: Enter insured and policy details first.
03

Enter Loss Details: Record dates, causes, amounts, and status.
04

Attach Documents: Upload supporting files and contact details.

Typical Digital Workflow Configuration

Configure a structured workflow for capture, verification, and retention to ensure data quality and auditability.

Field	Configuration
Owner	Agent or insured completes initial entry.
Storage	Store as PDF/A with secure audit trail.
Authentication	Use email or SMS code for signer verification.
Routing	Automatically route to underwriting and claims.

How Electronic Submission Typically Flows

Electronic submission follows a short sequence from upload to signed record, preserving an audit trail for each action.

Upload Document: Submit completed form and attachments.
Place Fields: Add signature, date, and data fields.
Send to Signer: Deliver via email or direct link.
Receive Signed Copy: Store signed PDF and certificate.

Platform Capabilities to Look For

Use a platform that supports secure transmission, audit trails, and clear signer attribution to meet legal and operational needs.

Encryption: TLS and AES-256
Audit Trail: Timestamps and IP logs
Authentication: Email or SMS code

Common Timelines and Processing Expectations

Timelines vary by carrier and complexity; plan for vendor requests and allow time for verification, review, and appeals.

Request Timing:

Often requested at application, renewal, or upon claim notice.

Initial Response:

Expect 7–14 business days for insurer acknowledgement.

Underwriting Review:

Allow 5–15 business days for underwriting decisions.

Document Retrieval:

Policyholders should allow 10–30 days for document collection.

Appeals Period:

Carrier-specific; commonly 30–60 days for disputes.

Risks of Inaccurate or Incomplete Forms

Claim Denial: Missing info can trigger denial

Premium Increase: Underestimated exposure leads to higher premium

Coverage Rescission: Material misstatements risk rescission

Regulatory Action: Filing errors may prompt regulator review

Subrogation Loss: Incomplete records hinder recovery

Audit Delay: Insufficient evidence slows audits

Security and Compliance Considerations

Encryption: TLS 1.2/1.3 in transit

Data At Rest: AES-256 encryption

Certifications: SOC 2 Type II and ISO 27001

HIPAA: BAA available for PHI

Audit Trail: Detailed timestamps and logs

Accessibility: WCAG 2.0 Level AA support

eSignature Vendor Pricing and Feature Snapshot

Comparison of common eSignature options for completing and storing completed Insurance Loss History Forms; signNow appears first per table rules.

	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 by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies by plan	Varies by plan	Varies by plan

Frequently Asked Questions

Answers to common questions about completing, submitting, and validating the Insurance Loss History Form.

Need help? Contact support

What is this form used for?
The form summarizes prior claims and losses to assist underwriting, premium setting, and claims evaluation. Insurers use it to detect patterns, assess residual risk, and decide coverage terms for new or renewing policies.
Who must sign the form?
An authorized representative of the insured or the named insured typically signs. Agents may attest to received documents but signatures should come from an authorized officer or individual with binding authority.
Can the form be e-signed?
Yes. Electronic signatures are legally valid under ESIGN (15 U.S.C. ch. 96) and UETA in most states, provided intent, consent, attribution, and retention requirements are met for the transaction.
What if data is missing or incorrect?
Missing or inaccurate entries can cause underwriting delays, increased premium, or claim denial. Correct errors promptly and provide supporting documentation to the requesting carrier to avoid adverse action.
How long does processing take?
Processing varies by carrier and complexity; simple verifications often take 7–14 business days, while complex loss reviews or litigation-related claims may take substantially longer.
Are notarization or witnesses required?
Not usually required for routine loss histories, but sworn affidavits or certain state forms may demand notarization or witnesses. Check state-specific rules before execution for legally sensitive statements.

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