STATEMENT GUIDE

STRUCTURAL FIRE - INSURED

Opening
This is (name of adjuster) conducting a recorded interview (in person or by telephone) with
(name of person being interviewed) on (date of interview) concerning an incident which took
place on (date of incident) at (location of incident).
Permission
1. Do you understand that this interview is being recorded?
2. Is it being recorded with your permission?
Identification
1. Would you state your full name, and spell your last name, please?
2. What is your date of birth?
3. What is your social security number?
4. What is your home address?
5. What is your home, cell, and work telephone numbers?
6. Are you single or married?
- What is your spouses name?
- What are the names and ages of your children?
- Do they all live in this dwelling?
Employment
1. Where are you employed?
2. Who is your supervisor?
3. How long have you worked there?
4. What is the nature of your job?
Accident Date, Location & Weather
1. What was the date and time of the incident?
2. What were the weather conditions?
3. Exactly where did the incident occur?
4. How did you first become aware of the fire?
- Where were you when you first became aware of the fire?

Guide 2010S
2004 Nationwide Publishing Company, Inc.
http://www.claimspages.com
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STATEMENT GUIDE
STRUCTURAL FIRE - INSURED
Structure Information
1. How old is the structure?
- Prior to the fire, describe any electrical or any other problems with the structure.
- Were there any blown fuses?
- Were there any problems with any electrical equipment?
2. Who built the structure?
3. Who owns the structure?
If not interviewee, do you rent this location?
- What is your monthly rent?
- What are the terms of your lease agreement?
If interviewee, when did you purchase the structure?
- Who did you purchase it from?
- Who is the mortgagee?
- What is your monthly payment?
- Are your payments current?
- Is there a 2nd or 3rd mortgage on the structure?
- Explain any other property you have on this mortgage.
- Is the structure used as security on any other type of loan?
- What changes have been made to the structure since you purchased it?
4. How was the structure heated?
5. Where is the electrical panel located?
- Was there any recent repair work to this panel?
- What was done to it?
- What is the name and phone number of the person or company that repaired it?
6. Were there any smoke alarms in the structure?
- Where were they located?
- Are they battery powered or electric?
- When was the last time the batteries were replaced?
- Who replaced them?
- Did they go off during the fire?
7. Was there a sprinkler system in the structure?
- Where was it located?
- Did it activate during the fire?
8. Were there electrical appliances located in the structure?
- Where were they located?

Guide 2010S
2004 Nationwide Publishing Company, Inc.
http://www.claimspages.com
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STATEMENT GUIDE
STRUCTURAL FIRE - INSURED
9. Describe the structure.
- What type of flooring was in the structure?
- What type of finishing was on the walls?
- Describe where and how many windows were in the structure?
- What type of furnishings were in the structure?
- Were any furnishings removed prior the fire starting?
Incident Details
1. Tell me about the incident.
- Where was the fire first observed?
- What color was the flame?
- What color was the smoke?
- Was there an identifiable odor?
- What was it?
- Describe any sounds you heard?
- Was the fire low in relation to the ceiling or floor?
- Was it near a corner?
- What was burning?
- Was fire observed anywhere else in the structure?
- Where was it observed?
- Where did the fire spread to in the structure?
- Explain anything unusual that took place during the fire?
- Were there any explosions?
- Was there a change in the color of the flame or the smoke?
- Were any lights on in the structure during the fire?
- Describe any windows that popped-out.
- Describe any part of the roof or wall that may have caved-in.
2. Who else was present when you observed the fire?
- What actions were taken by you when you observed the fire?
- What actions were taken by everyone else?
3. Who reported the fire to the fire department?
- How long did it take for the fire department to arrive?
- Which fire department responded to the fire?
- How long did it take to extinguish the fire?
- Did the fire department break in to the structure?
- Where did they enter?

Guide 2010S
2004 Nationwide Publishing Company, Inc.
http://www.claimspages.com
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STATEMENT GUIDE
STRUCTURAL FIRE - INSURED
Structural Damage
1. Describe the damage to the structure.
2. List all content items that were damaged in the fire?
- Are you making any payments on any of these contents?
- Who are you making your payments to?
- Are your payments current?
3. What business records were damaged in the fire?
Police / Fire Investigation / Post Incident Discussions
1. Where did the fire originate?
- List everything in the room where the fire originated and its location.
- Were there overhead light fixtures in this room?
- Where were they located?
- When were they installed?
- Who installed them?
2. What is the name, address, and phone number of the last person in the room of origin?
- Why were they in the room?
3. What electrical appliances are in the room of origin?
- Were they turned off prior to the fire occurring?
- Who turned them off and when did this occur?
4. Did anyone smoke in the room of origin?
- What is the name of last person who smoked in the room?
5. Are there any candles used in this room?
- If yes, were they extinguished prior to the fire?
6. Have there been any drastic changes in the utility bills lately for any unknown reason?
7. Have there been any unusual odors in the structure?
- What type of odor?
- Was this odor reported to anyone?
- Who reported it and who received the report?
- When was this reported?
- What was done after it was reported?
8. Do you have any idea as to what caused the fire?
- How do you know this information?
9. Did you overhear any conversation between the fire and police department?
- What was said in these conversations?
- Did either party say anything to you?
- What was said?
Guide 2010S
2004 Nationwide Publishing Company, Inc.
http://www.claimspages.com
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STATEMENT GUIDE
STRUCTURAL FIRE - INSURED
Whereabouts
1. Do you have any pets?
- What type of pets do you have?
- Where were the pets during the fire?
- If removed from the structure, why were they removed?
2. Please explain your whereabouts 24 to 48 hours prior to the fire starting?
3. What are the names, addresses, and telephone numbers of the people you were with?
4. Did you start this fire?
5. Did you pay anyone to start this fire?
6. Do you have any other knowledge as to how this fire started?
Witnesses
1. Were there any witnesses to this fire?
- What are their names, addresses, and telephone numbers?
- Where were they located during the fire?
Injuries & Lost Wages
1. Were you injured in this fire?
- What type of injury did you have?
- Were you treated in a hospital?
- Which hospital? Where?
- How long were you confined?
- What doctor is treating you for your injuries?
- Have you recovered from the injuries which you sustained?
- Describe any expenses or losses you incurred as a result of your injuries?
- Were you required to lose time from your employment?
- For what period of time?
2. Was anyone else injured in this fire?
- Who was injured?
- What type of injuries did they have?

Guide 2010S
2004 Nationwide Publishing Company, Inc.
http://www.claimspages.com
5

STATEMENT GUIDE
STRUCTURAL FIRE - INSURED
Previous Incidents
1. Have you ever had or witnessed any other structural or automobile fire?
- Explain the details of the incident.
- When did it occur?
- Where did it occur?
- What was the cause of the fire?
- Were you injured?
- What type of injury did you receive?
- How long were you out of work?
Suspects
1. Have you had any problems with anyone at work or at home?
- What are their names, addresses, and telephone numbers?
2. Has there been any construction or electrical work done in the area lately?
- What and where was this done?
3. Can you think of anyone who may have started this fire?
Closing
1. Is there anything you would like to add regarding this incident?
2. Have you understood all of the questions asked?
3. Is all of the information that you have given true to the best of your knowledge?
4. Do you understand that this interview has been recorded?
5. Was it recorded with your permission?
Thank you. This concludes our interview.

Guide 2010S
2004 Nationwide Publishing Company, Inc.
http://www.claimspages.com
6