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Insurance Loss Run Request Form

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INSURANCE LOSS RUN REQUEST FORM

Insured / Applicant Information

Contact Person:

Phone:

Email:

Date of Birth (if individual insured):

Federal Tax ID / SSN (last 4 digits if required):

Requesting Party (Recipient of Loss Runs)

Requesting Contact:

Phone:

Email:

Policy Information (Provide each policy to be searched)

Carrier Name:

Policy Type:

Policy Period From:

To:

Policy Type:

Policy Period From:

To:

If additional policies exist, attach a separate sheet with the same data fields and sign this form to authorize full release for all listed policies.

Requested Loss Run Content & Claim Filters

Please indicate items to include in the loss run (check all that apply):

Claim status filters:

Loss occurrence date range (to filter results): From To

Delivery Preferences

Preferred delivery method (check one or more):

Exclusions, Limitations & Conditions

The carrier may withhold privileged communications, attorney work product, or materials not subject to release by law. Requested documents that are outside the carrier's retention period may not be available. This request does not expand coverage nor constitute acceptance of liability by the carrier. The carrier's response will be limited to information maintained in its claims handling system.

Authorization and Certification

I hereby certify that I am authorized to request and receive loss run and claim information for the insured named above. I authorize the named carrier and its representatives to release claim and loss information to the Requesting Party identified on this form for underwriting, risk management, or claim review purposes. I understand that information released pursuant to this request may include personal data and claim-specific financial information.

I agree to hold harmless and indemnify the carrier and its representatives for disclosures made in good faith pursuant to this authorization. I certify under penalty of perjury that the information on this form is true and correct to the best of my knowledge and that I have the authority to execute this request on behalf of the insured.

Acknowledgment of Identity and Authority

By signing below, the signer affirms that they are an authorized officer, partner, owner, or authorized representative of the insured and has the legal authority to request release of claim information. If signing on behalf of the insured, please indicate capacity below.

Printed Name:

Signature:

Date:

Company / Organization:

Phone:

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What the Insurance Loss Run Request Form Is and when it’s used

The Insurance Loss Run Request Form is a standardized request used to obtain an insurer’s historical claims data for a named policy or insured. It lists claim dates, claim numbers, causes of loss, paid amounts, open reserves, and status for a specified period. Brokers, underwriters, risk managers, and insureds use loss runs during renewals, placements, acquisitions, audits, or litigation to evaluate frequency, severity, and loss development. The form typically identifies the policy, the insured, authorizing party, and the date range to ensure accurate retrieval of records.

Why a formal loss run request matters for underwriting accuracy

Using a formal Insurance Loss Run Request Form produces consistent, auditable claim data, reduces repeated information requests, and helps brokers and underwriters assess risk exposure and pricing quickly during renewals or placements.

Why a formal loss run request matters for underwriting accuracy

Who typically prepares or requests loss runs

Typical users who prepare or request loss runs include insurance brokers, risk managers, and policyholders seeking underwriting clarity.

  • Insurance brokers assessing renewal terms and searching for claim trends to advise clients.
  • Risk managers compiling loss history for internal reporting, budgeting, and safety programs.
  • Underwriters verifying exposure, reserves, and prior claims before quoting or binding coverage.

Accurate loss runs improve pricing accuracy and support faster coverage decisions by all parties involved.

Key signers and requesters of loss runs

Broker

Brokers request loss runs on behalf of clients during renewals, M&A, or placement changes. They analyze claim frequency and severity, negotiate terms, and document prior carrier handling to support placement or ceded coverage decisions; accurate forms speed placement and reduce premium surprises.

Insured

Policyholders or company risk officers complete or authorize requests to give carriers access to historical claim data. They confirm policy identifiers and sign authorizations to avoid delays and ensure underwriters receive correct, complete loss histories for pricing and risk management.

Security and compliance considerations for loss run transmission

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest
Audit Trail: Detailed timestamps, IP, and action logs
HIPAA: Compliant with BAA required
ESIGN / UETA: Recognizes electronic signatures nationwide
21 CFR Part 11: Support for FDA electronic records
Access Controls: Role-based access and 2FA support

Risks and potential consequences of incorrect loss run requests

Coverage Denial: Unreported claims may lead to denial
Higher Premiums: Undisclosed frequency increases rates
Underwriting Delays: Incomplete data delays renewal
Regulatory Risk: Improper PHI sharing risks HIPAA fines
Contract Disputes: Mismatched records trigger disputes
Tax Consequences: Backup withholding if TIN errors

Common preparation mistakes that slow carrier responses

  • Providing incorrect policy numbers or insured names causes insurers to return requests or produce incomplete loss histories, delaying underwriting and renewals.
  • Failing to include explicit authorization or signed release can prevent carriers from sharing third-party claim details due to privacy policies or state law.
  • Requesting overly broad date ranges without clarification increases processing time and may include irrelevant claims, obscuring underwriting analysis.
  • Submitting low-quality scanned documents or unreadable attachments forces manual transcription and increases error rates in the loss run record.

Step-by-step: completing the Insurance Loss Run Request Form

Follow these steps to prepare and submit an Insurance Loss Run Request Form accurately to speed insurer response and reduce follow-ups.

  • 01
    Gather Details: Collect policy numbers, insured name, and coverage periods.
  • 02
    Complete Form: Enter required fields and sign authorization.
  • 03
    Attach ID: Include proof of authorization or power of attorney.
  • 04
    Submit: Send to carrier via certified mail or secure eSubmission.

How a loss run request is processed from submission to return

This outlines the typical routing and processing steps carriers follow after receiving a completed request and authorization.

  • Upload: Attach completed form and supporting documents.
  • Carrier Review: Insurer verifies authorization and locates records.
  • Produce Report: Carrier compiles loss run and reserves data.
  • Deliver: Carrier returns report by email or secure portal.

Essential components to include on a professional loss run request

Include clear, standardized fields and authorization language to reduce carrier queries and ensure returned reports match underwriting needs.

Standardized Fields

Predefined fields for policy number, NAIC code, and insured legal name reduce ambiguity and streamline carrier search across legacy systems and third-party administrator databases.

Authorization

Clear signed authorization or proof of consent specifying the requester, scope, and period prevents privacy-based refusals and documents legal permission to release loss information.

Claim Details

Request specific columns such as claim number, date of loss, cause, status, paid amount, and open reserves to allow underwriters to assess frequency and severity.

Reserve History

Include requested fields for initial reserve, changes, case reserve, and payment history to evaluate loss development and potential future exposure.

Coverage Period

Specify exact from/to dates, policy inception and expiration, and any endorsements or lapse periods to ensure the carrier returns the correct records.

Audit Evidence

Ask for carrier notes, loss adjuster identifiers, and claim notes when available; these context fields explain unusual reserves or handling practices.

Practical best practices for accurate and speedy loss run retrieval

Follow these practical steps to reduce processing time, avoid disputes, and maintain accurate underwriting records across renewals and audits.

Confirm identity and authorization details
Provide a photocopy of a government ID or company letterhead authorization when the requester is not the named insured. State the relationship to the insured to prevent carrier refusals and speed verification.
Use precise date ranges and policy identifiers
Enter exact MM/DD/YYYY start and end dates, and include policy effective/expiration dates. Avoid vague phrases like 'past claims' which can lead to incomplete or inconsistent returns and additional insurer follow-ups.
Request specific claim fields
List the exact columns you need (claim number, date of loss, cause, status, paid, reserves). Clear field requests reduce manual reformatting and accelerate underwriting review.
Retain copies and logs
Keep signed request copies, delivery receipts, and the carrier's response. Retention supports audits, dispute resolution, and proof of authorized access under privacy regulations.

Typical timelines and internal deadlines for loss run requests

Expect varying carrier response times and set internal follow-up checkpoints to avoid renewal delays or underwriting bottlenecks.

Standard Response Time:

7–21 business days typical.

Expedited Requests:

May require fee; 2–5 business days.

Follow-up Reminder:

Send reminder at 10 business days.

Notarized Requests:

Add RON or in-person notary time.

Record Retention:

Store responses for at least 3–7 years.

Pricing and plan contrasts for eSignature vendors relevant to loss run workflows

Compare starting prices and key feature criteria for popular eSignature providers used to collect, notarize, and store loss run requests and authorizations.

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 Yes, 7-day 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
Envelope Cap No cap 100 envelopes/user/year Varies Varies Varies

Frequently asked questions about Insurance Loss Run Request Forms

Answers to frequent questions about preparing, authorizing, and receiving Insurance Loss Run Request Forms and carrier responses accurately.


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