This is a sworn statement of loss to be sent to an insurance carrier in connection with a
claim. The statement provides the type of loss and the damage that occurred to
property. In addition, the policyholder must provide the insurance policy number, the
date the policy was issued, and the date the policy expires. This statement must be
certified by a notary public to ensure the proper identification of the policyholder. This
statement can be used by individuals or entities that want to provide a statement of loss
to their insurance carrier.
SWORN STATEMENT OF LOSS
Re: Claim Number ___________ [Instruction: Insert Number]
1. Insured Information.
A. Name: ___________ [Instruction: Insert Policyholder Name]
B. Address: ___________ [Instruction: Insert Address ]
C. Insurance Policy Number: ___________ [Instruction: Insert Policy Number]
D. Date Policy Issued: ___________ [Instruction: Insert Date]
E. Date Policy Expires: ___________ [Instruction: Insert Date]
2. Loss Information.
A. Date of Loss: ___________ [Instruction: Insert Date]
B. Time of Loss: ___________ [Instruction: Insert Time]
C. Cause and Origin of Loss: ___________ [Instruction: Insert Description of What
Happened Causing Loss]
D. Loss Property:
i. Address: ___________ [Instruction: Insert Address of Property]
ii. Title and Interest: At the time of the loss, the policyholder held title to the insured
property. No other persons had any interest therein or encumbrance thereon, except:
___________ [Instruction: Insert Mortgage Company and any other person with title to
home].
iii. Changes: Since the insurance policy was issued, the property has not been assigned,
nor has there been a change of interest, use, occupancy, location or exposure of the property,
except: ___________ [Instruction: Insert If There Has Been Changes to Status of the
Property].
iv. Value: The actual cash value of the property at the time of the loss was:
$___________ [Instruction: Insert Amount]
v. Loss: The whole loss and damage was: $___________ [Instruction: Insert
Amount]
E. Loss Articles:
i. Description of Articles: ___________ [Instruction: Insert Description of Lost
Articles]
ii. Title and Interest: At the time of the loss, the policyholder held title to the articles
described herein. No other persons had any interest therein or encumbrance thereon, except:
___________ [Instruction: Insert Mortgage Company and any other person with title to
home].
iii. Value: The actual cash value of the articles at the time of the loss was: $___________
[Instruction: Insert Amount]
iv. Loss: The whole loss and damage was: $___________ [Instruction: Insert
Amount]
3. Amount Claimed. The amount claimed under the above numbered policy is: $___________
[Instruction: Insert Amount]
4. Statement of the Insured. I, ___________ [Instruction: Insert Policy Holder Name] (the
“Insured”), being duly sworn, avow that: (i) the Insured is the policyholder named herein; (ii) the
information is being provided to obtain payment under the insurance policy described herein;
(iii) The loss described herein did not originate by any act, design or procurement on the part of
the Insured; (iv) nothing in connection with the loss was done by or with privity or consent of the
Insured; (v) the Insured has done nothing to violate or invalidate the provisions of the insurance
policy; (vi) no articles or property mentioned herein were destroyed or damaged prior to the time
of the loss; (vii) no articles or property has been, in any manner, concealed in connection with
the loss; (viii) the Insured has made no attempt to deceive the insurance company as to the extent
of the loss in any manner; and (ix) the above information is true, correct, and complete to the
best of the Insured's knowledge, information, and belief.
_________________________________
[Instruction: Sign]
_____________ [Instruction: Insert Policy Holder
Name]
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State of ________________________
County of _______________________
Sworn to and subscribed before me on ___________________________________________.
_______________________________________________________
Notary Public
My Commissi