Statement of Loss - Insurance Claim

This is a statement by an insured party directed to an insurance company swearing to the nature and circumstances of a claimed loss.

Date policy issued: Enter the date of issuance of the policy

Date policy expires: Enter the date of expiration of the policy


To the Enter the name of the insurance company.

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

Enter the name of the insured

against loss by Enter type of insurance, upon the property described by the under Schedule "A," according to the terms and conditions of the same policy and all forms, endorsements, transfers and assignments attached thereto.

Time and origin: A Enter the reason for loss loss occured about the hour of Enter approximate time of loss The loss occurred, on State the date of loss. The cause and origin of said loss were:

Enter cause for the loss

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:

Enter occupancy of structure

Title and Interest: At the time of the loss the interest of your insured in the property described therein was The property claimed was.

Changes. Since the said policy was issued there has been no assignment thereof, or change of interest, use, occupancy, location or exposure of the property described, except:

Enter any change in use or occupancy

Total insurance. The total amount of insurance upon the property described by this policy was, at the time of the loss, $ Enter the policy limits of the coverage (Enter the policy limits of the coverage Dollars) as more particularly specified in the apportionment attached under Schedule "C," besides which there was no policy or other contact of insurance, written or oral, valid or invalid.

The actual cash value of said property at the time of the loss was $ Enter the total value of the damaged items (Enter the total value of the damaged items Dollars).

The Whole Loss and Damage was $ Enter the total amount of damages (Enter the total amount of damages Dollars)

The amount claimed under the above numbered policy is $ Enter the amount claimed (Enter the amount claimed Dollars)

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

County of Enter county where executed

Subscribed and sworn to before me this Day of Month, Year

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