Sworn Statement In Proof Of Loss (No Subrogation)

This document is a formal Sworn Statement in Proof of Loss that outlines the framework for insured parties to officially declare a loss with their insurance company, specifically in scenarios where subrogation is not applicable. This comprehensive statement includes:

• Amount of Policy at Time of Loss and Policy Number
• Detailed information on the Date Issued, Date Expires, and Agent
• Comprehensive details of the loss, including Time and Origin, Occupancy, Title and Interest, Changes since the policy was issued, Total Insurance, and the Actual Cash Value of the property at the time of the loss
• The calculated Whole Loss and Damage, Less Amount of Deductible, and the Amount Claimed under the policy
• Declarations affirming the loss did not originate by any act, design, or procurement on the part of the insured or the affiant, and adherence to policy conditions
• Notarization section for official authentication of the statement
• Schedules “A,” “B,” and “C” for detailed listing of policy form, actual cash value, loss and damage, and apportionment of insurance coverage
• Receipt for Payment section to acknowledge the settlement of claims
• A notice on insurance fraud, highlighting the legal implications of filing deceptive claims

Designed to ensure a clear, lawful, and comprehensive documentation of loss, this form is crucial for the accurate and fair processing of insurance claims, particularly in cases exempt from subrogation rights.