Insurance Claim Form
An insurance claim form has to capture the facts while they're fresh: exactly when, exactly where, exactly what, and who else was involved. Detail collected on day one is worth ten times detail recalled on day thirty.
For brokers, agents and insurance teams.
Ask for the time, not just the date
Claims are decided on specifics: the time of day, the weather, the sequence of events, who said what. All of it is available on the day it happened and half of it is gone a fortnight later.
So this template prompts for a sequence rather than a summary, asks whether the incident was reported to police or another authority, and asks for third-party details including insurer and plate. Those are the fields a claims handler otherwise chases for a week.
A record with a timestamp
Every submission is stored with the moment it was made, and exports as a spreadsheet. If a report ever has to be produced - for an insurer, a regulator, a review - it exists, dated, unedited.
Enough detail to quote, not enough to be a nuisance
Quoting needs specifics - cover type, value, dates, claims history - and every extra question loses people. The answer is to ask the ones that change the premium and nothing else, in one short pass.
Claims and renewals work the same way: ask the facts that let you act, keep it short enough that a stressed client finishes it, and have it in writing from the start.
Route it to the right person
Send every report to whoever needs to act on it by email the moment it arrives, so nothing sits in a queue waiting to be noticed.
One minute to make it your own
Every label, option and placeholder on this template is editable, and you can add whatever this template doesn't ask. Save to publish, share the link, and export the responses whenever you need them in a spreadsheet.
What this template asks
- Policyholder name
- Policy number
- Email address
- Phone number
- Type of policy
- Date it happened
- Approximate time
- Where did it happen?
- What kind of incident?
- What happened?
- What was damaged, lost or injured?
- Estimated value of the loss
- Was anyone else involved?
- Their details
- Were there witnesses?
- Witness names and contact details
- Was it reported to anyone?
- Reference or crime number
- A link to photos, video or documents
- What do you have?
- The information I have given is true and complete to the best of my knowledge
More Insurance forms
Questions
Can claimants upload photos or documents?
Not yet - ask for a link, or tell them what to email in reply. Capturing the structured facts here is what shortens the claim; the images follow.
Should the form warn about fraud?
A plain, non-accusatory note that claims are verified and that false information can void a policy is standard and reduces exaggeration. Keep it short and factual.
Can reports be submitted anonymously?
Yes, if you make the name optional. Nothing about the submitter is recorded otherwise - no IP address, no account, no tracking.
Can this go to more than one person?
Yes. Notification recipients are a list, so a report can reach a manager and a safety lead at the same time.
Can I export everything for an audit?
Yes - one click gives you a CSV of every response with its timestamp, which is usually exactly what an auditor or insurer asks for.
Is it suitable for claims information?
For dates, descriptions and contact details, yes, and the timestamped record is useful. Don't collect full bank details or identity documents through a web form; ask for those through a channel designed for it.
Publish your insurance claim form today
Start from this template and change anything you like. Free to begin.