Sworn Statement And Proof Of Loss Form printable pdf download

Sworn Statement And Proof Of Loss Form

SWORN STATEMENT AND PROOF OF LOSS

Declare that:

I am an Insured named under policy number

My current address is

My permanent address (Parent’s Address) is

Date of Incident:

Location of Incident:

Description of Loss (What happened?)

Police Authorities which were notified:

Date they were notified:

By whom were they notified:

I have other insurance on the same property in the amount of $

The name of the insurance company carrying this insurance is

They have been notified:

Yes

They have made a payment in the amount of $

That this Company may require from the Insured an assignment of all rights of recovery against any

party for loss to the extent that payment therefore is made by this Company.

We must advise you that any person knowingly and with intent to defraud any insurance company

or other person files a statement of claim containing any materially false information, or conceals

for the purpose of misleading, information concerning any fact material thereto, commits a

fraudulent insurance act, which is a crime.

The above statements are true and correct to the best of my knowledge

Haylor, Freyer & Coon, Inc.

Signature: ___________________________ Date:_____________

PO Box 4743

Syracuse, NY 13221

Address: _____________________________________________

Fax 315-453-2184

Telephone #: _________________________

Email Address: _______________________

QF.CL.06 -3/9/11

Sworn Statement And Proof Of Loss Form