Establishing secure connection…Loading editor…Preparing document…

Insurance Statement of Diligent Effort

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

INSURANCE STATEMENT OF DILIGENT EFFORT

Insurer and Agent

Insurer / Company:

Agent or Broker Name:

Applicant / Insured Information

Date of Birth:   Policy Number:

Policy Details

Coverage Amount:   Deductible:   Premium:

Policy Period From:   To:

Purpose of Statement

Purpose (select all that apply):

Locate Insured / Applicant    Notify Beneficiary    Obtain Missing Documents    Other:

Beneficiary / Contact Information

Relationship:   Allocation Percentage:

Statement of Diligent Effort — Certification

I, the undersigned, certify that I have undertaken a documented, good-faith effort to accomplish the purpose(s) indicated above with respect to the insured and policy identified herein. The efforts described below were performed contemporaneously with the events described and constitute the complete record of efforts over the applicable period. This statement is made to induce the insurer to rely on the described efforts in connection with underwriting, claims handling, or beneficiary notification.

Attempt Log (record each substantive attempt)

Attempt 1

Date:   Time:   Contacted:

Method(s): Phone Email First-class Mail Certified Mail In-person Other:

Attempt 2

Date:   Time:   Contacted:

Method(s): Phone Email First-class Mail Certified Mail In-person Other:

Attempt 3

Date:   Time:   Contacted:

Method(s): Phone Email First-class Mail Certified Mail In-person Other:

Attachments and Documentation Checklist

The following documents are attached to support this statement (check all that apply):

Copies of written notices/letters    Certified mail receipts    Voicemail transcript / call log

Address verification / forwarding information    Copy of identification    Other:

Exclusions and Limitations

This Statement of Diligent Effort documents the efforts of the undersigned and does not, by itself, create, extend, or modify the terms of any insurance policy. The insurer reserves all rights under the policy, including but not limited to defenses, exclusions, and coverage determinations. The undersigned acknowledges that the insurer may rely on the information and attachments provided herein in making underwriting or claims determinations.

Declaration and Authorization

I declare under penalty of perjury that the information contained in this Statement of Diligent Effort is true, complete, and correct to the best of my knowledge. I certify that the efforts described were undertaken in good faith and that the attached documentation accurately reflects the actions taken. I authorize the insurer and its representatives to retain this statement and to use or disclose the information contained herein as necessary for underwriting, claims handling, or legal compliance.

Agent / Preparer (if different from insured)

Preparer Contact Phone:   Preparer Email:

Printed Name:

Signature:

Date:

By signing above, the applicant attests that the foregoing is true under penalty of law and authorizes release of records necessary to verify the efforts described herein.

Enter text✕
Prepare your document for signing right on this page
  • 01 Edit the text and complete the fields
  • 02 Click Sign Now and on the next screen add recipients and signature fields in SignNow
  • 03 Start your free trial to sign and send your doc
Sign Now

What the Insurance Statement of Diligent Effort Is

An Insurance Statement of Diligent Effort documents the steps a claimant, insurer, or third party took to contact an insured, verify coverage, or obtain required information before a coverage determination, claim denial, or subrogation action. It records dates, methods (phone, mail, email), names contacted, and outcomes. The form establishes a factual timeline showing reasonable attempts to reach a party or to collect supporting evidence, and it is commonly used in claims handling, underwriting exceptions, and regulatory audits to demonstrate procedural compliance.

Why this statement matters for claims and compliance

A clear Statement of Diligent Effort provides an audit-ready record that supports claim decisions, shows adherence to internal procedures and regulatory expectations, and reduces dispute risk by detailing contact attempts and results in a reproducible format.

Why this statement matters for claims and compliance

Typical parties who complete or rely on the statement

Accurate completion helps downstream teams, auditors, and regulators review the sequence and adequacy of contact efforts.

  • Claims examiners documenting outreach attempts before denying or closing a claim.
  • Underwriters capturing verification steps for coverage investigations or policy issuance exceptions.
  • Third-party administrators and subrogation teams preserving evidence of attempts to identify liable parties.

Who signs and certifies the completed statement

Claims Manager

A supervising claims manager certifies that recorded attempts reflect the department's reasonable procedures and authorizes any administrative action. The manager's narrative should explain exceptions, delegated authorities, and escalations relevant to the recorded outreach.

Field Adjuster

A field adjuster or assigned examiner signs to confirm specific contact attempts, dates, and results. Their signature attests to the factual content and may be relied on in internal reviews, litigation, or regulatory examinations.

Core components to include on a professional statement

A complete Insurance Statement of Diligent Effort combines identification data, a chronological log of contact attempts, method details, results, supporting attachments, and a certification by the responsible party to create a defensible record.

Document Header

Policy and claim identifiers, claimant and insured names, policy number, claim number, and the responsible office or adjuster. This top-level data links the statement to the claim file and downstream systems.

Attempt Log

A dated, sequential record of each contact attempt including time, method (phone, email, certified mail), recipient name, and the outcome — left voicemail, no answer, wrong number, or successful contact.

Method Details

For each attempt record the specific channel used, account or phone number, SMS or email content summary, and any tracking numbers for certified or registered mail to support verification.

Supporting Evidence

Attach call logs, delivery receipts, returned mail, screenshots, or correspondence. Clearly label attachments and reference them next to each relevant attempt entry in the log.

Summary and Conclusion

A concise statement summarizing total attempts, the last date of successful contact (if any), and a recommended next step — close claim, reopen, refer to subrogation, or escalate to legal.

Certification

A dated signature block for the preparer and a supervisory sign-off area verifying accuracy and completeness. Include printed name, title, and contact information for follow-up.

Essential identifying and compliance fields

Policy Number: Policy identifier
Claim Number: Claim identifier
Insured Name: Full legal name
Dates of Contact: MM/DD/YYYY entries
Method Used: Phone, email, mail
Preparer Signature: Signer name and date

Step-by-step: completing the Insurance Statement of Diligent Effort

Follow these sequential steps to create a complete, auditable statement that accurately reflects outreach and verification efforts.

  • 01
    Gather identifiers: Collect policy and claim numbers first.
  • 02
    Log each attempt: Record date, time, method, and outcome.
  • 03
    Attach proof: Include call logs and delivery receipts.
  • 04
    Certify and file: Sign, date, and save in the claim file.

Where the completed statement goes in the workflow

Routing the completed statement maintains chain of custody and ensures the record is available for underwriting, audit, and legal review.

  • Claims File: Store in the primary claim record.
  • Underwriting: Send a copy when coverage issues arise.
  • Subrogation: Attach to recovery or third-party actions.
  • Regulatory Response: Provide on request for audits or exams.

Recommended digital workflow settings for e-submission

Configure your digital workflow to capture evidence, require signer attribution, and retain an immutable audit trail.

Field Configuration
Timestamping Enable automatic timestamp on all sign and save actions
Attachment Required Make supporting evidence uploads mandatory for closure
Signer Authentication Use email plus SMS or stronger methods for critical attestations
Audit Trail Retain IP, action log, and version history

Technical considerations for eSubmission and storage

Use systems that produce tamper-evident signed PDFs and keep metadata and attachments linked to the statement for auditability.

  • File Formats: PDF, DOCX preservation
  • Authentication: Email + SMS or higher
  • Integrations: Connectors for claims systems

Timing considerations and typical deadlines

Timeframes vary by policy and jurisdiction; document attempts promptly and follow insurer-specific notice or appeal deadlines.

Immediate Recording:

Log attempts same day to preserve accuracy

Insurer Notice Windows:

Follow policy-specified reporting and response periods

Appeal Periods:

Observe insurer or statutory appeal deadlines

Subrogation Timelines:

Begin preservation steps promptly to avoid spoilage

Regulatory Requests:

Respond within regulator-specified response windows

Common mistakes to avoid when preparing the statement

  • Failing to timestamp each attempt creates ambiguity about sequence and timeliness of outreach.
  • Using vague outcomes ('left message') without specifics prevents recipients from assessing adequacy of effort.
  • Not attaching proof such as delivery receipts or call logs undermines the statement's evidentiary value.
  • Allowing inconsistent formats for dates, names, or identifiers complicates system searches and audit reconciliation.

Consequences of an incomplete or incorrect statement

Claim Denial Risk: Delayed or denied claims
Regulatory Scrutiny: Increased examiner review
Subrogation Loss: Weakened recovery position
Litigation Exposure: Greater evidentiary challenges
HIPAA Breach: Potential privacy penalties
Operational Delay: Slower claim resolution

Representative eSignature pricing and feature comparison

Compare common vendor price points and core capabilities relevant to completing, signing, and storing Insurance Statements of Diligent Effort.

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 trial No No Yes, limited Yes, limited
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 env/user/yr Varies Varies Varies

Frequently asked questions about the Insurance Statement of Diligent Effort

Answers to common questions about validity, signatures, storage, and evidence to help preparers avoid procedural errors.


Need help? Contact support

be ready to get more
Join over 28 million airSlate SignNow users
Sign Now
Company
Forms
Pricing
Resources
Knowledge base
Other Products
© 2026 airSlate Inc. All rights reserved.