Sworn Statement in Proof of Loss

Fill this out right here on the page, then hit Print / Save as PDF — or grab the Blank PDFto print and complete by hand. This is a generic Florida form for reference; always compare it against the exact Proof of Loss your insurance carrier sent you and return it within their deadline.

Notary required. A Proof of Loss must be signed before a notary. If your contractor is also a notary, they cannot notarize it — a notary can’t profit from the signature they witness.

Sworn Statement in Proof of Loss

State of Florida — Generic Property Insurance Proof of Loss

Insurance Company (To)Policy NumberClaim / Loss NumberAgent / AgencyAmount of Policy at Time of Loss

Insured & Property

Name of Insured(s)Property / Loss AddressCity

StateZIP

Mailing Address (if different)

Details of the Loss

Date of LossTime of Loss (approx.)Cause / Origin of Loss (e.g. windstorm, hurricane, fire)Occupancy at Time of Loss (owner-occupied, rental, vacant)Who Owned the PropertyWho Occupied the PropertyMortgage Holder / Lien Holder(s)Other Insurance on This Property (company & amount)Any Change in Title, Use, or Occupancy Since Policy Issued?

Amounts Claimed

Whole Loss & Damage

Actual Cash Value

Less Deductible

Amount Claimed Under This Policy

Amount Previously Paid

Balance Due Claimant

The insured, being duly sworn, deposes and says that the foregoing is a true and complete statement of the loss; that no attempt to deceive the said insurance company as to the extent of said loss has in any manner been made; and that no articles are mentioned herein but such as were destroyed or damaged at the time of said loss.

Signature of InsuredDate SignedSignature of Co-Insured (if any)Date Signed

Notary Acknowledgment

State ofCounty of

Sworn to (or affirmed) and subscribed before me this ____ day of ____________, 20____, by the above-named insured, who is personally known to me or produced ____________________ as identification.

Notary SignatureNotary Printed NameCommission NumberMy Commission Expires

(Affix notary seal)

Generic reference form provided by P1Mitigators™ (Jacksonville, FL). This is not legal advice and does not replace the specific Proof of Loss required by your carrier. Return the form your insurer sent, complete and notarized, within their stated deadline. Questions? Call P1Mitigators at (904) 891-8435 or contact your desk adjuster.

Tip: to email a completed copy, fill it out here, click Print / Save as PDF, then choose “Save as PDF” as the printer destination. You’ll get a clean PDF you can send. For a hand-completed copy, use the Blank PDF button up top.