Insurance Claim Field Assessment Form
Complete this form to document findings and observations during an insurance claim site visit.
Assessor Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Claim Reference Number
*
Type of Damage Observed
*
Fire
Water/Flood
Storm/Wind
Theft/Vandalism
Other
Severity of Damage
*
Minor
1
2
3
4
Severe
5
1 is Minor, 5 is Severe
Site Accessibility
*
Easily accessible
Partially accessible
Not accessible
Safety Hazards Present
*
None
Structural instability
Electrical hazards
Chemical exposure
Other
Assessment Summary Table
*
Rows
Not Observed
Partially Observed
Fully Observed
Property damage
1
2
3
Contents damage
4
5
6
Site secured
7
8
9
Immediate repairs needed
10
11
12
Are all required photographs and documents attached?
*
Yes
No
Additional Comments or Observations
Submit Assessment
Should be Empty: