Claims Investigation and Fact Gathering
Purpose and sequence
Investigation answers three questions: what happened, what the policy says, and what is owed. The sequence is first notice of loss, triage and verification, coverage check, evidence gathering, proof of loss, and evaluation. Confirm the policy was in force, the named insured matches, and the loss date and location fit.
Evidence tools
Use recorded or written statements, examination under oath (EUO) where the policy or statute allows, photographs and video, scene inspection, police, fire, and weather reports, medical records with authorization, financial records, and estimates. For property claims, secure the scene, document pre-existing damage, and preserve chain of custody for samples. For liability claims, obtain the claimant's statement, witness names, and the incident report; photograph injuries and property.
Duties you must police
Insureds owe prompt notice, cooperation, proof of loss, and mitigation. Late notice is a defense only where the policy requires prejudice or a statute allows it. Issue a reservation of rights letter when coverage is uncertain and never promise coverage or value early.
Traps
- Taking a statement that suggests answers rather than asking open questions.
- Failing to document a spouse's or contractor's statements.
- Skipping the weather or alarm record that would corroborate or refute the loss.
- Demanding an EUO where it is not authorized.
- Letting a claimant's demand letter set the investigation deadline.
Rule of thumb
If it is not in the file, it did not happen. Write a dated, factual contact note after every call.
Worked example: A water loss is reported 40 days late because the insured was traveling. The adjuster documents the delay, obtains the plumber's invoice and shut-off date, and checks the notice condition. If the policy requires prejudice, the insurer must show harm from the delay, not merely the delay itself.