Insurance Claim Viability Assessment Questionnaire
Assess whether an insurance claim is likely viable by providing the incident, coverage, and supporting documentation details.
Claim Overview
Claim reference number or internal claim ID
*
Policy type
*
Auto
Home
Renters
Commercial
Life
Travel
Other
Date of incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of incident
*
Date claim was first noticed or reported
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Incident Details
Incident description
*
Cause or event type
*
Collision
Theft
Water damage
Fire
Storm
Liability incident
Injury-related incident
Other
Estimated date and time of incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Was the incident witnessed or documented?
*
Yes
No
Unsure
Coverage And Viability Assessment
Coverage Status
*
Likely covered
Possibly covered
Likely not covered
Unsure
Claim Viability Rating
*
1
2
3
4
5
Deductible Awareness
*
Yes
No
Unsure
Key Viability Factors
*
Rows
Yes
No
Unknown
Policy active at time of loss
1
2
3
Incident falls within coverage
4
5
6
Supporting documentation available
7
8
9
Reporting was timely
10
11
12
Loss And Documentation
Estimated loss amount range
*
Under $1,000
$1,000–$5,000
$5,000–$10,000
$10,000–$25,000
$25,000+
Property or item affected
*
Supporting documents available
Photos
Police report
Repair estimate
Receipts
Witness statement
Correspondence
None yet
Additional notes for the adjuster or reviewer
Submit
Should be Empty: