SWORN INSURANCE CLAIM STATEMENT — Starter Template
Provided free by Thistlegate Notary Office. This is a starting point, not legal advice.
Bring this statement UNSIGNED to your appointment — it must be sworn before the notary.

SWORN STATEMENT IN PROOF OF LOSS

Policyholder: ____________________________  Policy No.: ____________________
Address: ________________________________________________________________
Phone: ____________________  Email: ____________________

Insurer: ____________________________  Claim No. (if known): ____________________
Date of loss: ____________________  Time: ____________________
Place of loss: ____________________________________________________________

Description of what happened:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Property / items lost or damaged:
1. ____________________________  Value: $____________  Receipt attached: Y / N
2. ____________________________  Value: $____________  Receipt attached: Y / N
3. ____________________________  Value: $____________  Receipt attached: Y / N

Total amount claimed: $____________

Other insurance covering this loss: ________________________________________

I declare under penalty of perjury that the above is true and correct, that no
relevant fact has been withheld, and that I submit this claim in good faith.

________________________________________
Claimant signature (sign before the notary)   Date: ____________________

Printed name: ____________________________