Insurance Claim Form Template
A free insurance claim form for agencies and brokers. Clients report a loss online with the date, policy, what happened, photos and a signed statement.
Customize the pages and design to fit your needs.
About this template
Let policyholders report a loss the day it happens. Collect the policy number, type of loss, date and place, a description, photos and police report details, then a signed statement that it's accurate.
Common uses
- Insurance agencies and brokers
- First notice of loss
- Property, auto and theft claims
Key features
- Policy and loss details
- Photo and document uploads
- Signed statement
What this template asks
What's your full name?
Short Text
What's your email address?
Email
What's your phone number?
Phone
What's your policy number?
Short Text
What type of claim is it?
Single Choice · Auto accident, Property damage, Theft, Injury, Something else
When did it happen?
Date
Where did it happen?
Short Text
What happened?
Long Text
Was a police report filed?
Short Text · Optional
Upload photos or documents
File · Optional
Sign to confirm this claim is accurate
Signature
How to use this template
Copy it
Select Use template and a copy opens in your workspace as an unpublished draft.
Make it yours
Edit any question or answer, choose a theme, and add your logo.
Share it
Publish, then send the link, show a QR code, or embed the form on your site. Responses arrive in Submissions.
Frequently asked questions
What information does an insurance claim form need?
The policyholder, policy number, type of loss, date and location, what happened, photos, any police report number and a signed statement.
Can clients add photos of the damage?
Yes. Clients upload photos and documents from their phone, saved with the claim.
Does this replace the insurer's own claim form?
No. It helps your agency collect the first notice of loss quickly. You still submit the claim to the carrier the way they require.