Claim Red Flag Indicator Checklist

This template is for first-party and third-party claims where the adjuster needs to record red flags before making a referral decision. It fits property, auto, liability, workers’ compensation, and similar files that rely on statements, documents, and loss history. It is not a coverage determination form and does not replace claim handling procedures or legal review. Use it when the file needs a structured fraud or irregularity screen.

Use it at intake and again whenever new facts, documents, or witness statements change the file picture. Many teams run it once at first notice of loss and a second time before reserve changes, payment approval, or denial. If the claim develops slowly, rerun it after each major document upload or interview. The goal is to capture red flags when they first appear, not after the file is closed.

The primary adjuster usually completes it, with supervisor or peer review for borderline files. If your process includes SIU triage, the adjuster should document the facts and let a reviewer decide whether referral is warranted. The checklist works best when the person closest to the file records observable facts, not assumptions. Final escalation should follow your company’s claim authority matrix.

No. It is a screening and documentation tool that helps justify whether a referral should happen. If your organization already has an SIU intake form, this checklist can feed it with cleaner notes, timestamps, and evidence references. It is most useful when you want a consistent threshold for escalation across adjusters and offices.

The biggest mistake is treating suspicion as proof instead of documenting specific, observable discrepancies. Another common issue is leaving out dates, source documents, or why a statement conflicts with the evidence. Teams also miss pattern signals when they only review the current loss and ignore prior claims history. A good checklist entry should show what was observed, where it came from, and why it matters.

Yes. You can tailor the wording for auto, property, liability, workers’ compensation, or specialty lines while keeping the same red-flag structure. For example, auto claims may emphasize repair estimates, telematics, and vehicle damage consistency, while workers’ compensation may emphasize medical timing, work restrictions, and witness statements. Keep the sections intact so reviewers can compare files consistently.

It creates a documented trail showing that the adjuster reviewed behavioral cues, evidence consistency, and claim patterns before escalating. That supports disciplined claim handling under general insurance governance expectations and helps avoid unsupported accusations. The checklist should stay factual, neutral, and tied to records, photos, interviews, and timestamps. It is a process aid, not a legal conclusion.

Yes. The checklist can be used as a form inside a claim platform, exported to PDF, or linked to SIU intake notes and task queues. Many teams map the primary red flags to a severity score or referral trigger in their workflow system. If you integrate it, keep the evidence fields and reviewer sign-off so the output remains auditable. The template is also easy to pair with document management and photo upload tools.