Sworn Statement in Proof of Loss at a glance
What it is: Sworn Statement in Proof of Loss, pursuant to S. 817. 234, Florida Statutes, for a claim under an insurance policy.
Who signs: Each insured signs on a Signature of Insured line and enters the Print Name.
A filled-in Sworn Statement in Proof of Loss example: two owners claim a fire loss
How to fill out Sworn Statement in Proof of Loss, box by box
Amount of Policy and Policy Number
Enter the Amount of Policy at Time of Loss, the Policy Number and the Agent; the row also prints Date Issued and Date Expires.
Claim, insured, date and time of loss
Enter the Name of Insurance Company, the Claim Number and the Named Insured(s).
Enter the Date of Loss and the Time of Loss with a.m./ p.m.
Cause of Loss
Under Cause of Loss, enter The cause and origin of the said loss were.
Title and Interest and Names of Mortgages/Lienholders
Under Title and Interest, write your interest in the property involved at the time of loss.
Write the Names of Mortgages/Lienholders.
Other than the insureds and any and all loss payees indicated in the policy of insurance, there are no other persons who have an interest or lien in the property involved, except for named mortgage or lienholders, except: write any exception after it.
Other policies and changes in title or occupancy
Write the other policies of insurance which may cover the loss.
Describe changes in title to the property during the policy term or changes in occupancy of property during policy term.
Total Insurance and Actual Cash Value
Enter the total amount of insurance upon the property described by this policy at the time of loss, as more particularly specified in the policy declarations sheet.
Enter the Actual Cash Value of said property at the time of loss.
Loss and Damage
Enter the loss and damage as follows: Building, Other Structure(s), Contents, Adjusted Living Expenses ("ALE"), The Whole Loss Total, Deductible, and Whole Amount Claimed Minus Deductible.
The specifications of damaged buildings, if applicable, are contained in the attachments hereto; the specifications of damaged contents, if applicable, are contained in the attachments hereto; if applicable, ALE or rental loss receipts are attached hereto.
Signing before the notary public
The undersigned certify that the statements and information contained herein with respect to the loss reported are accurate and truthful to the best of [his/her/their] knowledge and belief.
The loss did not originate by any act, design, or procurement on your part; no property has been concealed, and no attempt to deceive the said company as to the extent of the loss has been made.
Each insured signs on a Signature of Insured line and enters the Print Name.
Sign before a Notary Public, State of Florida; the Notary Public enters State of Florida, County of; Sworn to and subscribed to before me on this day of, 20; and Personally known, or Produced.
Common questions about Sworn Statement in Proof of Loss
Is there a penalty?
Any person who, with the intent to injure, defraud, or deceive any insurer or insured, prepares, presents, or causes to be presented a proof of loss or estimate of cost or repair of damaged property in support of a claim under an insurance policy knowing that the proof of loss or estimate of claim or repairs contains any false, incomplete or misleading information concerning any fact or thing material to the claim commits a felony of the third degree.
Sources
[1] Sworn Statement in Proof of Loss, Florida (no issuer file) (the Official source link on this page).
