Sworn Proof Of Loss Form PDF Details

When disaster strikes, and one encounters loss or damage to their property, navigating the aftermath and filing an insurance claim can feel like navigating through a storm. The Sworn Proof of Loss form plays a pivotal role in this journey towards recovery, serving as a critical document that policyholders must submit to their insurance companies to initiate the claims process. This form, meticulously detailed, requires the insured to present a comprehensive account of the loss sustained, including descriptions of the insured property, the circumstances surrounding the loss, the value of the property both before and after the loss, and the amount claimed for compensation. It operates under the premise of utmost honesty, expecting the insured to make a sworn statement regarding the truthfulness of the information provided, which is then verified in front of a notary public. Embedded within this process are clauses that caution against the provision of false, incomplete, or misleading information, highlighting the legal ramifications, such as felony charges, which deter fraudulent claims. This form, therefore, not only facilitates the efficient processing of claims by providing insurance companies with the necessary information but also underscores the principles of integrity and accountability that govern the insurance industry. By completing the Sworn Proof of Loss form with accurate and thorough details, policyholders take a crucial step towards obtaining the financial assistance to rebuild and recover from their loss.

QuestionAnswer
Form NameSworn Proof Of Loss Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namessworn statement in proof of loss pdf, proof of loss template, statement of loss, statement of loss form

Form Preview Example

POLICY NUMBER

_______________

POLICY AMT. AT TIME OF LOSS

$_____________________________

DATE ISSUED

______________________________

DATE EXPIRES

______________________________

Sworn Statement

IN

PROOF OF LOSS

COMPANY CLAIM NUMBER

_____________________________________

AGENT

_________________________________

AGENCY AT

_____________________________________

To the __[INSURANCE COMPANY NAME]_________________________________________________________________

of _____[CITY STATE]___________________________________________________________________________________

At time of loss, by the above indicated policy of insurance you insured-

________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

against loss by ___________________________ to the property described according to the terms and conditions of said policy and of all forms,

endorsements, transfers and assignments attached thereto.

TIME AND

A ________________ loss occurred about the hour of _____o'clock AM/PM., on the ______ day of __________, 20__ .

 

ORIGIN

The cause and origin of the said loss were: ____________________________________________________________________

 

OCCUPANCY

The building described, or containing the property described, was occupied at the time of the loss as follows, and for no other

 

purpose whatever: ______________________________________________________________________________.

 

TITLE AND

At the time of the loss, the interest of your insured in the property described therein was________________________ INTEREST

CHANGES

________________________________________________________ .

No other person or persons had any interest therein or

 

encumbrance thereon, except: ______________________________________________________________________________

 

 

Since the said policy was issued, there has been no assignment thereof, or change of interest, use, occupancy,

possession, location

 

or exposure of the property described, except

 

 

 

 

_______________________________________________________________________________________________________

TOTAL

THE TOTAL AMOUNT OF INSURANCE upon the property described by this policy was, at the time of the loss,

 

 

$ ______________________________, as more particularly specified in the apportionment attached, besides which there was no

 

policy or other contract of insurance, written or oral, valid or invalid.

 

 

 

VALUE

THE ACTUAL CASH VALUE of said property at the time of the loss was

. . . . . . . . . . . . $ _____________________________

LOSS

THE WHOLE LOSS AND DAMAGE was

. . . . . . . . . . . . .$ ____________________________

 

AMT. CLAIMED

THE AMOUNT CLAIMED under the above numbered policy number is………………... . $______________________________

STATEMENTS

The said loss did not originate by any act, design or procurement on the part of your insured, or this affiant; nothing has

 

OF INSURED

done by or with the privity or consent of your insured or this affiant, to violate the conditions of the policy, or render it void;

no

 

articles are mentioned herein or in annexed schedules but such as were destroyed or damaged at the time of said loss; no property

 

saved has in any manner been concealed, and no attempt to deceive the said company, as to the extent of said

loss, has in

any

 

manner been made. Any other information that may be required will be furnished and considered a part of this proof.

 

The furnishing of this blank or the preparation of proofs by a representative of the above insurance company is not a waiver of any of its rights.

State Of____________________________

Insured:_______________________________________________________

County Of _________________________

Insured:_______________________________________________________

Subscribed and sworn to before me this _____________

day of ______________________________________________, ________

Personally Known to Me ________________

 

I.D. _________________________________

Notary:_______________________________________________________

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURANCE COMPANY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.

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In an effort to fill out this document, ensure you provide the right details in each and every blank field:

1. For starters, while filling out the insurance statement proof of, begin with the section that has the following blanks:

Filling in segment 1 of proof of loss template

2. Just after filling out the previous step, head on to the subsequent part and fill in the necessary details in these fields - POLICY NUMBER POLICY AMT AT TIME, The building described or, time of the loss, THE WHOLE LOSS AND DAMAGE was, loss has, and THE ACTUAL CASH VALUE of said.

proof of loss template conclusion process detailed (part 2)

3. Through this stage, review POLICY NUMBER POLICY AMT AT TIME, and ANY PERSON WHO KNOWINGLY AND WITH. These need to be completed with greatest accuracy.

Part no. 3 for filling in proof of loss template

Those who use this document generally get some points wrong while filling out ANY PERSON WHO KNOWINGLY AND WITH in this part. Don't forget to review what you enter here.

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