This is a sworn statement of loss to be sent to an insurance carrier in connection with a
claim for a vehicle loss. The statement provides the type of loss and the damage that
occurred to the vehicle. 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 vehicle 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 Vehicle:
i. Make/Model/Year: ___________ [Instruction: Insert Make/Model/Year]
ii. State/License Number: ___________ [Instruction: Insert License Plate Number]
iii. VIN: ___________ [Instruction: Insert Vehicle Identification Number]
iv. Title and Interest: At the time of the loss, the policyholder was the sole owner of the
vehicle. No other persons had any interest therein, by lease, bailment, mortgage, lien or other
encumbrance, except: ___________ [Instruction: Insert Lease Company and/or any other
person with title to vehicle].
v. Other Insurance: At the time of the loss, there was no other insurance policy covering
the vehicle except: ___________ [Instruction: Insert Other Insurance Company].
vi. Use of Vehicle: At the time of the loss, the vehicle was being used for: ___________
[Instruction: Insert Use of Vehicle, i.e. personal or business use], and was not being used to
carry passengers for compensation or rental or leased, or for any illegal or non-covered loss
except: ___________ [Instruction: Insert Use of Vehicle].
vii. Value: The actual cash value of the property at the time of the loss was:
$___________ [Instruction: Insert Amount]
viii. 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 vehicle mentioned herein were destroyed or damaged prior to the time
of the loss; (vii) no articles or vehicle 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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