Claim Red Flag Indicator Checklist

Inspection checklist for adjusters to document behavioral, documentation, and pattern-based claim red flags that may warrant closer scrutiny and SIU referral.

Claim Intake and Loss Narrative

• Loss date, time, and location are consistent across all claim documents
• Reported mechanism of loss is plausible and matches the physical evidence described
• Claimant provided a clear, detailed, and non-evasive statement
• There are unexplained delays between the loss event and claim reporting
• The claim involves unusual urgency, pressure, or repeated follow-up to accelerate payment

Behavioral Red Flags

• Claimant or witness was reluctant to provide basic information or documentation
• Statements appear rehearsed, coached, or materially identical across different interviews
• Observed behavior is inconsistent with the reported injury, damage, or claimed limitations
• There are signs of malingering, exaggeration, or symptom magnification
• The claimant has an unusual history of prior claims, prior similar injuries, or repeated loss patterns

Documentation and Evidence Review

• Required supporting documents are complete and legible
• Medical, repair, or incident records contain inconsistencies with the reported facts
• There are signs of altered, duplicated, or potentially fabricated documents
• Photo, video, or digital evidence supports the reported claim timeline and severity
• Document submission dates and metadata align with the stated sequence of events

Pattern and Exposure Analysis

• The loss pattern is unusual compared with similar claims or expected exposure
• Multiple losses, repeated repairs, or recurring injuries are present in the claim history
• The claim involves multiple parties, addresses, vehicles, providers, or entities with unclear relationships
• There are indicators of staged, inflated, or coordinated loss activity
• The claim has been referred previously for peer review, SIU review, or similar investigation

Referral Decision and Follow-Up

• SIU referral is warranted based on documented red flags
• Peer review or supervisor review is recommended before claim disposition
• Primary red flags identified
• Recommended next action
• Reviewer sign-off