Formal sworn statement submitted by an insured to their insurer detailing the facts, cause, and dollar amount of a covered loss, as typically required under property and inland marine insurance policies.
The Sworn Statement in Proof of Loss is a ready-to-use insurance & risk template you can send for signature in minutes. It is written for 1 signer (insured) and, by default, expires 30 days after it is sent if left unsigned. It covers proof of loss, sworn statement, property insurance, claim documentation, insurance claim. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Sworn Statement in Proof of Loss **Statement Date:** ___________ --- ## 1. Insured Information **Insured Name (as it appears on the policy):** ___________ **Insured Mailing Address:** ___________ **Insured Daytime Phone:** ___________ **Insured Email:** ___________ --- ## 2. Policy Information **Insurance Company:** ___________ **Policy Number:** ___________ **Policy Type:** ___________ If Other, specify: ___________ **Policy Period:** ___________ to ___________ **Claim Number:** ___________ --- ## 3. Loss Information **Date of Loss / Damage:** ___________ **Time of Loss (approximate):** ___________