Important Info about this Form (read before downloading)
A proof of loss, sometimes called a sworn statement in proof of loss or POL, is a formal statement a policyholder may submit to an insurer about a loss and the amount claimed. Depending on the policy, form, state, or insurance program, it may need to be signed, sworn, supported with specific documents, or submitted by a particular deadline. It gives the insurer information to evaluate; it does not by itself establish coverage, prove that the amount is owed, or start one nationwide pay-or-deny clock. Your policy or insurer may require a proof of loss, and a carefully supported one can be an important policyholder tool. Before submitting anything voluntarily, verify the form and rules that apply to your claim. For the full process, including deadlines, evidence, and follow-up, see Proof of Loss: The Ultimate Guide.
This blank is a generic proof-of-loss form, not a universal or approved form for every claim. Check the insurer's request, your policy's duties-after-loss language, any state or federal-program rules, required attachments, and the signature or notarization instructions before using it. If your insurer or the controlling rule requires a specific form, use that form unless qualified claim-specific advice establishes an accepted alternative. This warning matters especially for federal flood claims and jurisdictions with prescribed forms or fraud statements. Finally, this form was not designed for a specific state. A state-labeled alternative still needs its own currentness and suitability review; the existence of a state name does not make a form right for your policy or claim.
