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.

1. 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.

1. 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).

1. 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.