---
name: proof-of-loss-sufficiency
source: https://app.decimal.ai/s/proof-of-loss-sufficiency@1/SKILL.md
source_sha256: f902380a0cde
---

# Proof-of-loss sufficiency screen

You are handed a first-party claim submission — the items the insured has filed and the
dates involved. Decide one thing: is the file **complete** and ready to send to coverage
adjudication, or is it **deficient**? Return exactly one decision. On deficient, itemize
every element that is missing or late. Do **not** rule on whether the loss is covered —
that is a separate step that only starts once the file is complete.

The failure this fixes: treating any written claim as a valid submission, waving a file
through with "looks mostly there," or ruling on the merits of an incomplete file. A file
is **deficient if any single required element is missing, unsworn where an oath is
required, or filed past its window** — one gap is enough.

## The two deadlines are different

The most common error is collapsing *notice* and *proof of loss* into one thing. They are
two separate requirements with two separate clocks:

- **Notice** (first notice of loss) — telling the carrier a loss happened. Due within the
  policy's notice window: "prompt," "as soon as practicable," or a fixed number of days
  from the loss.
- **Proof of loss** — a **signed, sworn** statement of the amount and details of the loss.
  Due within its own deadline, commonly **60 days** from the loss or from the carrier's
  request. A proof of loss that is **not signed and sworn** (under oath / notarized where
  the policy requires) is **not a valid proof of loss**, no matter how detailed.

Timely notice does not excuse a missing or late proof of loss, and vice versa. Screen both.

## Gates

Run all four. The file is **complete** only if every gate passes. Collect every failure —
unlike a stop-on-first screen, list *all* deficiencies so the insured can cure them in one
return, not one at a time.

1. **Notice timeliness.** Was the loss reported within the policy's notice window? Reported
   late (past the stated days, or long after the loss where "prompt" applies) → deficiency
   `late-notice`.

2. **Sworn proof of loss.** Is a proof of loss present, **signed and sworn**, and filed
   within its deadline? Missing → `no-proof-of-loss`. Present but unsigned/unsworn →
   `unsworn-proof-of-loss`. Present and sworn but past the deadline → `late-proof-of-loss`.

3. **Peril-specific documents.** Are the documents this peril requires all present? Use the
   checklist below. Any missing → name each one (e.g. `missing: police report`).

4. **Cooperation-clause compliance.** Has the insured met cooperation duties the carrier has
   invoked — attend an examination under oath (EUO) if requested, produce requested records
   or receipts, and allow inspection/access to the damaged property? A refused EUO,
   unproduced requested records, or denied inspection → `cooperation-failure` (name which).

## Peril document checklists

These are the items required *in addition to* notice and a sworn proof of loss.

- **Fire / smoke** — itemized inventory of damaged/destroyed property; fire department or
  origin-and-cause report; photos of the damage.
- **Theft / burglary** — a **police report** (with report number); itemized list of stolen
  property; proof of ownership/value (receipts, appraisals) for scheduled or high-value items.
- **Water / plumbing** — a plumber or mitigation contractor report identifying the source;
  mitigation/repair invoices; photos of the damage.
- **Wind / hail** — a roof or property inspection or contractor report; repair estimate;
  photos; date-of-loss corroboration where the storm date is disputed.
- **Auto — collision / comprehensive** — a repair estimate; photos of the vehicle damage;
  a police report where there was another vehicle, injury, or theft.
- **Liability / bodily injury (third-party)** — the demand or claim from the third party;
  medical records and bills for a bodily-injury claim; any suit papers if served.
- **Business interruption** — financial records establishing the loss (profit-and-loss
  statements, tax returns, sales records); the period-of-restoration documentation.

If the peril is not listed, require at minimum: itemized proof of the loss amount, proof of
ownership/value, and evidence establishing the cause.

## Output

State the decision, then the reason(s).

- `COMPLETE — timely notice, sworn proof of loss within 60 days, police report and inventory present, cooperation met`
- `DEFICIENT — unsworn-proof-of-loss; missing: police report` (theft claim)
- `DEFICIENT — late-notice; no-proof-of-loss`
- `DEFICIENT — cooperation-failure: insured declined the requested examination under oath`

## Notes

- Screening gates adjudication — it runs **before** any coverage decision. Never proceed to
  the merits on a deficient file; return it with the itemized gaps.
- A signed-but-unsworn proof of loss is still deficient. The oath is the point of a *sworn*
  proof of loss; a signature alone does not satisfy it where the policy demands an oath.
- Only invoke cooperation duties the carrier has actually requested. Failure to attend an
  EUO that was never requested is not a deficiency.
- "Deficient" is not "denied." It means the file is not yet screenable on the merits — the
  insured can usually cure the gaps within the policy's cure period.