Sworn Statement of Loss: Vehicle

Greg Stone Greg Stone
How To Use

This review list is provided to inform you about this document in question and assist you in its preparation. This statement is useful both for insurance claims and tax deductions for loss on your IRS and state forms.

Use a notary. Large organizations like the niceties of this approach.

Sworn Statement of Loss, Vehicle

TO: _____________________________
Regarding: _______________________
Policy number: ____________________
Policy period: _________________ to __________________

By the above-mentioned policy of insurance, you insured ______________________________, (hereinafter called the insured) against loss or damage to the automobile described as follows:

Model Year: _______________
Make: ____________________
Type of body: ______________
VIN: _____________________
State/License number: _______________________

A loss caused by __________________ occurred on ___________________, about the hour of _________, as follows: _______________________________________

The insured was the sole owner of the automobile at the time of the loss or damage and no other person had any interest therein, by lease, bailment, mortgage, lien or other encumbrance or otherwise except: ______________________________________________________________________________________________________

At the time of this loss, there was no other insurance on said automobile covering the same periods except: _________________________________________________

At the time of this loss, the automobile was used for: ___________________ and was not being used to carry passengers or for compensation or rental or leased, or for any illegal or non-covered loss except: ___________________________________________

The said loss or damage did not originate by any act, design or procurement on my (our) part nor on the part of anyone having an interest in the party insured, or in the said policy of insurance; not in result or consequence of any fraud done or suffered by me/us and that no property saved has been concealed.

It is expressly understood that the furnishing of this blank or the preparation of this proof by a representative of the above insurance company, ____________________, is not a waiver of any of its rights.

By Owner

State of __________________
County of _________________

Sworn to and subscribed before me on _______________.

Notary Public

My Commission Expires: _______________________