
SWORN STATEMENT IN PROOF OF LOSS
PURSUANT TO S. 817. 234, FLORIDA STATUTES, ANY PERSON WHO, WITH THE INTENT TO INJURE, DEFRAUD,
OR DECEIVE ANY INSURER OR INSURED, PREPARES, PRESENTS, OR CAUSES TO BE PRESENTED A PROOF OF
LOSS OR ESTIMATE OF COST OR REPAIR OF DAMAGED PROPERTY IN SUPPORT OF A CLAIM UNDER AN
INSURANCE POLICY KNOWING THAT THE PROOF OF LOSS OR ESTIMATE OF CLAIM OR REPAIRS CONTAINS
ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION CONCERNING ANY FACT OR THING MATERIAL TO
THE CLAIM COMMITS A FELONY OF THE THIRD DEGREE, PUNISHABLE AS PROVIDED IN S. 775.082,
S.775.803, OR S.775.084, FLORIDA STATUTES.
$__________________________________________ ________________________________________________
AMOUNT OF POLICY AT TIME OF LOSS POLICY NUMBER
___________________ _______________________ ________________________________________________
DATE ISSUED DATE EXPIRES AGENT
1. Name of Insurance Company:____________________________________________________________________________
2. Claim Number: ___________________________ 3. Named Insured(s)______________________________
4. Date of Loss: _____________________________ 5. Time of Loss: _________________________[a.m./ p.m]
6. Cause of Loss: The cause and origin of the said loss were:______________________________________________________
________________________________________________________________________________________________________
7. Title and Interest: [My/Our] Interest in the property involved at the time of loss was as follows: ____________________
_____________________________________________________________________________________________
8. Names of Mortgages/Lienholders :________________________________________________________________________
________________________________________________________________________________________________________
Other than the insureds and any and all loss payees indicated in the policy of insurance, there are no other persons who have an
interest or lien in the property involved, except for above named mortgage or lienholders, except:
________________________________________________________________________________________________________
9. Other policies of insurance which may cover the loss: ________________________________________________________
10. Describe changes in title to the property during the policy term or changes in occupancy of property during policy
term:___________________________________________________________________________________________________
11. Total Insurance: The Total amount of insurance upon the property described by this policy was, at the time of loss
$__________________________, as more particularly specified in the policy declarations sheet.
12. The Actual Cash Value of said property at the time of loss was: $_______________________________________________
13. Loss and Damage: The specifications of damaged buildings, if applicable, are contained in the attachments hereto; The
specifications of damaged contents, if applicable, are contained in the attachments hereto; If applicable, ALE or rental loss
receipts are attached hereto. The loss and damage is as follows:
Building: $________________________
Other Structure(s) $________________________
Contents $________________________
Adjusted Living Expenses ("ALE") $________________________
The Whole Loss Total: $________________________
Deductible: $________________________
Whole Amount Claimed Minus Deductible $________________________
The loss did not originate by any act, design, or procurement on your part; no property has been concealed, and no attempt to
deceive the said company as to the extent of the loss has been made. The undersigned certify that the statements and information
contained herein with respect to the loss reported are accurate and truthful to the best of [his/her/their] knowledge and belief.
_________________________________________ ____________________________________________
Signature of Insured Signature of Insured
Print Name:______________________________________ Print Name ___________________________________
State of Florida, County of ______________
Sworn to and subscribed to before me on this ________ day of ____________________________________ , 20 _______ .
Personally known, or
Notary Public, State of Florida_________________________ Produced :_____________________________________