Cover · free template

Insurance Loss Run Request

Request loss runs from a current or former insurer with clear policy details, reporting dates, requester authorization, and instructions for delivery.

A ready-to-use insurance form for small teams who need a reliable intake process: 15 questions, 2 pages, 2 conditional rules.

Questions
15
Pages
2
Layouts
classic · card
Time to complete
≈ 6 min
Conditional rules
2
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Live preview and test console

This is the real form. Answer it to test the 2 conditional rules — nothing is sent or stored.

Page 1 of 2 — Identify the Policies

Request Insurance Loss Runs

Copy the insured name exactly as it appears on the policy.

Enter the insurer that issued the policies, not the agency that arranged them.

List each policy number and its effective and expiration dates, one policy per line. Flag any missing numbers.

For Other, identify the coverage alongside the policy numbers.

First day of the requested history period.

Last day of the requested history period. Include periods with no reported claims.

Every question on this page is currently visible.

Compliance checklist

Ready to publish
  • Payment items priced — passingEvery payment question charges a real amount, so a submission always records a payment.
  • Conditional logic resolves — passingEvery rule points at a question or page that exists in this template.
  • Financial disclaimer present — passingThis form does not provide financial, tax or legal advice. Any figures shown are indicative only and are not an offer of credit or a guarantee of terms. Please seek advice from a regulated adviser before making a decision.
  • Question labels unique — passingLogic and exports address questions by label, so duplicates are ambiguous.

What happens after submit: nothing is stored in this preview. On your own copy, every response triggers an instant email notification and lands in your response dashboard, ready to export or forward.

Happy with it? Take a copy into your workspace — every question, rule and setting comes with it.

Who this template is for

Insurance Loss Run Request is built for small teams who need a reliable intake process who need to collect the same complete information from everyone.

  • Small teams who need a reliable intake process working in insurance.
  • Teams who need to collect the same complete information from everyone without writing code or paying for a custom build.
  • Anyone replacing chasing missing details over email with one structured record per enquiry.
  • Respondents are the people you send it to — the form asks them 15 questions across 2 screens.
  • Mobile-heavy audiences, thanks to the one-question-per-screen card layout.

Why this form is useful

It removes the cost of chasing missing details over email and turns each submission into a record your team can act on immediately.

  • 12 questions are required, so submissions arrive complete instead of needing a follow-up email.
  • It collects a verified email address so replies and confirmations land.
  • It accepts a document or photo upload as evidence.
  • It pins the request to a specific date.
  • Conditional logic hides 2 questions until they are relevant — shorter forms convert better than long ones.
  • Splitting the form across 2 pages keeps each screen short and shows respondents how much is left.
  • Every response is stored, searchable and exportable, so nothing depends on one person's inbox.

How to use this template

From copy to live form is a few minutes of work, and every step is reversible.

  1. 1Press “Use this template” — a fresh copy of Insurance Loss Run Request lands in your workspace, ready to edit.
  2. 2Rename or delete any question, and change what is required. Nothing here is fixed.
  3. 3Open Notifications and add the email addresses that should be alerted on each submission; add an auto-reply to the respondent if the form collects an email address.
  4. 4Check the upload limits on the file question so respondents can attach what you actually need.
  5. 5Publish it, then either share the link directly or paste the embed snippet into your site — the embedded form resizes to fit and loads no marketing or advertising trackers.
  6. 6Watch responses land in Submissions, where you can filter, label and export them to CSV or PDF.

Logic and conditions blueprint

Exactly how this form behaves as it is answered — 2 conditional rules ship with it.

  • Features advanced show logic: if “Requester Relationship” is Authorized agent or broker, the form dynamically exposes “Authorization Document”. Otherwise that question never appears.
  • Features advanced show logic: if “Report Valuation” is Specific valuation date, the form dynamically exposes “Requested Valuation Date”. Otherwise that question never appears.
  • All 2 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.

About this template

A useful loss run request tells the insurer exactly which policies to search, which dates to cover, and where to send the report. Use this form for claims-history reports from current or former insurers, including periods when no claims were reported. It is not a way to open a new claim or change coverage. Keep each submission to one insurer and one line of coverage. List every relevant policy number, including expired policies, rather than relying on the current number to identify earlier terms. The requested history dates define the period to search; the valuation date describes how current the claim amounts and statuses should be. Those dates serve different purposes. Ask representatives to attach authorization only when applicable, and confirm the receiving insurer's requirements before forwarding the request. Avoid collecting claim narratives, medical records, or unrelated attachments. A loss run request usually needs policy identifiers, not the underlying claim file. Route submissions to the person who handles carrier follow-up. Treat the requested delivery date as a scheduling preference, not a promised turnaround. When the report arrives, check the insured name, policy periods, and valuation date before sharing it with the approved recipient.

What this form asks

Every question is editable — rename it, make it optional, or delete it entirely.

Page 1 — Identify the Policies

  • Named Insuredrequired
  • Insurance Carrierrequired
  • Policy Numbers and Termsrequired
  • Line of Coveragerequired
  • History Start Daterequired
  • History End Daterequired

Page 2 — Authorization and Delivery

  • Requester Namerequired
  • Requester Emailrequired
  • Requester Relationshiprequired
  • Authorization Document
  • Report Valuationrequired
  • Requested Valuation Date
  • Report Recipient Emailrequired
  • Requested Delivery Date
  • Authority to Request Recordsrequired

15 questions in total.

A Prior-Term General Liability Request

A fictional fixtures business requests its prior policy term's claims history for an upcoming insurance review.

Named Insured
Bramble Quay Fixtures LLC
Insurance Carrier
Juniper Lantern Insurance Company
Policy Numbers and Terms
GL-482716: July 1, 2024–June 30, 2025
History Start Date
2024-07-01
History End Date
2025-06-30
Report Valuation
Latest available valuation
Report Recipient Email
insurance@bramblequay.example

How the form changes as it's filled in

This template ships with 2 conditional rules, grouped into 2 behaviours driven by 2 questions. Everything below is already set up — edit or delete any rule once the template is in your workspace.

Driven by “Requester Relationship”

  • Reveals questions

    If “Requester Relationship” is Authorized agent or broker, the form reveals “Authorization Document”.

Driven by “Report Valuation”

  • Reveals questions

    If “Report Valuation” is Specific valuation date, the form reveals “Requested Valuation Date”.

Set it up step by step

  1. 1

    Separate requests by carrier

    Use one submission for each insurer and line of coverage. Include expired policy numbers so the carrier can locate earlier terms without guessing.

  2. 2

    Distinguish history from valuation

    Use the history dates for the period being searched. Select the latest available valuation unless the report recipient specifically needs a different as-of date.

  3. 3

    Check release requirements first

    Before sending an agent or broker request, confirm whether the carrier accepts the attached authorization or requires its own release. The form confirmation does not replace carrier verification.

  4. 4

    Track the request through receipt

    Assign a follow-up owner and record when the request reaches the carrier. Check the returned report for every requested policy term, including terms with no reported claims.

Mistakes to avoid

  • Naming the retail agency instead of the insurer that issued the policy.
  • Providing only the current policy number when requesting several years of history.
  • Treating the history end date as the valuation date and receiving claim figures that are less current than needed.

What it pairs with

Most teams don't run this form on its own. These are the forms and systems it sits next to.

What to do with the responses

Review the policy identifiers and requester authority, then send the request through the carrier's accepted channel. Track receipt and verify the returned report before delivering it to the approved recipient.

Works in both layouts

Browse classic templatesBrowse card templates

Forms that overlap this one

These pages cover the same subject ground as the insurance loss run request, matched on the words people actually search for.

Frequently asked questions

Can I request a loss run if there were no claims?

Yes. Include those policy terms in the request and ask the carrier to confirm the no-loss history rather than leaving the period undocumented.

How many years should I request?

Use the period requested by the intended report recipient. If this supports a Business Insurance Quote, confirm the history period needed before contacting former carriers.

Does submitting this form authorize release automatically?

No. It captures the requester's confirmation and any attached authorization, but the carrier may still require a signed release, identity checks, or its own request process.

What if a policy number or valuation date is unavailable?

Flag the missing policy number alongside the known term dates rather than inventing one. Choose the latest available valuation unless a particular date is needed; confirm any date-specific request with the carrier.

Is the Insurance Loss Run Request template free to use?

Yes. You can preview and test Insurance Loss Run Request on this page without an account, and take a copy into your own HelloForms workspace on the free plan. There is nothing to install and no card required to publish it.

What does the Insurance Loss Run Request template ask for?

It asks 15 questions across 2 pages, 12 of which are required. Every question is listed in full further down this page, and each one can be renamed, reordered, made optional or deleted after you copy the template.

Can I edit the Insurance Loss Run Request form after copying it?

Yes — the copy is entirely yours. Change wording, add or remove questions, switch between the classic and card layouts, restyle it to match your brand, and set who gets notified on each submission.

How does the conditional logic in this insurance form work?

2 conditional rules ship with the template: Features advanced show logic: if “Requester Relationship” is Authorized agent or broker, the form dynamically exposes “Authorization Document”. Otherwise that question never appears. Features advanced show logic: if “Report Valuation” is Specific valuation date, the form dynamically exposes “Requested Valuation Date”. Otherwise that question never appears. All 2 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other. All rules are editable in the Logic tab.

Where do responses to the Insurance Loss Run Request form go?

Submissions land in your workspace under Submissions, where you can search, filter, label and export them to CSV or PDF. You can also email a notification to your team on every submission and send the respondent an auto-reply.

Can I embed the Insurance Loss Run Request form on my own website?

Yes. Publish the form and paste the embed snippet into any page or share the direct link. The embedded form resizes to fit its container and loads no advertising or marketing trackers inside the iframe.

Can respondents upload files?

Yes. This template includes a file upload question, so respondents can attach documents or photos with their answers. You can adjust the accepted file types and size limits on that question.

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