# 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.

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.

Canonical: https://reuily.com/templates/insurance-claim-form
Use this template: https://reuily.com/form/from-template/insurance-claim-form
Collections: Requests & Intake, Finance & Insurance
Last updated: 2026-10-24

## Questions

- Question 1: What's your full name? (Short Text, required)
- Question 2: What's your email address? (Email, required)
- Question 3: What's your phone number? (Phone, required)
- Question 4: What's your policy number? (Short Text, required)
- Question 5: What type of claim is it? (Single Choice, required). Options: Auto accident; Property damage; Theft; Injury; Something else
- Question 6: When did it happen? (Date, required)
- Question 7: Where did it happen? (Short Text, required)
- Question 8: What happened? (Long Text, required)
- Question 9: Was a police report filed? (Short Text, optional)
- Question 10: Upload photos or documents (File, optional)
- Question 11: Sign to confirm this claim is accurate (Signature, required)

Signing records the signer's consent, email, IP address, browser and signing time, and each signer can download a signed PDF copy.

## 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

## 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.