Residential Fire & Theft Loss Sworn Proof of Loss Statement Form
Claimant / Insured Full Name
· · ·
Insured Property Address (Locati
· · ·
Current Mailing Address (if diff
· · ·
Submit
The Residential Fire & Theft Loss Sworn Proof of Loss Statement Form is a comprehensive document designed to help homeowners and renters formally report losses to their insurance provider. It captures all essential details including claimant and policy information, the date and type of loss, a full description of how the incident occurred, and the total claimed amounts.
This template is ideal for insurance companies, independent adjusters, and policyholders navigating the claims process after a fire or theft event. By collecting structured data such as police or fire department report numbers, incident timelines, and contact information, it ensures nothing is overlooked during the claims submission process.
Using a standardized digital form accelerates the claims review process, reduces errors, and creates a clear paper trail for both insurers and claimants. Customize this free template to match your organization's branding and compliance requirements, then share it instantly with affected policyholders.
4Pages
32Questions
~11minTo complete
FreeNo credit card needed
Field types
Short Text ×5
Yes / No ×4
currency ×4
File Upload ×4
Address ×3
Full Name ×2
Date ×2
Phone
Email
daterange
Time Picker
Dropdown
Long Text
termsandconditions
Signature
Questions in this template
Free template
The exact questions included — customize any of them to fit your needs.
Page 1Claimant & Policy Information9 questions
Claimant & Policy Information
1
Claimant / Insured Full Name
*Full Name
2
Insured Property Address (Location of Loss)
*Address
3
Current Mailing Address (if different from above)
Address
4
Claimant Phone Number
*Phone
5
Claimant Email Address
*Email
6
Insurance Company Name
*Short Text
7
Policy Number
*Short Text
8
Policy Period (Effective Date – Expiration Date)
*daterange
9
Claim / Loss Number
*Short Text
Page 2Loss Event Details12 questions
Details of the Loss
1
Date of Loss
*Date
2
Approximate Time of Loss
Time Picker
3
Type of Loss
*Dropdown
4
Detailed Description of How the Loss Occurred
*Long Text
5
Location Where Loss Occurred (if different from insured property)
Address
6
Was a police or fire department report filed?
*Yes / No
7
Report / Incident Number (if applicable)
Short Text
8
Were any other parties involved or responsible for the loss?
*Yes / No
Claimed Amounts
9
Total Amount of Loss Claimed for Building / Structure Damage
*currency
10
Total Amount of Loss Claimed for Personal Property / Contents
*currency
11
Total Amount of Loss Claimed for Additional Living Expenses
currency
12
Total Amount Claimed (All Categories Combined)
*currency
Please upload any documentation that supports your claim, including inventories of damaged or stolen property, photographs, receipts, repair estimates, police/fire reports, and any other relevant records.
1
Upload Itemized Inventory of Damaged / Stolen Property (spreadsheet or list)
*File Upload
2
Upload Photos or Videos of Damage / Loss
File Upload
3
Upload Police Report or Fire Department Report
File Upload
4
Upload Repair Estimates, Receipts, or Appraisals
File Upload
Other Insurance & Prior Claims
5
Is there any other insurance covering this loss?
*Yes / No
6
If yes, provide the other insurer name and policy number
Short Text
7
Have you previously filed a claim for this property within the last 5 years?
*Yes / No
Page 4Sworn Statement & Signature4 questions
Sworn Statement & Certification
I do hereby swear and affirm that the foregoing statements and information provided in this Proof of Loss are true, accurate, and complete to the best of my knowledge and belief. I understand that any willful misrepresentation, concealment of fact, or fraud in connection with this claim may result in denial of the claim and may subject me to criminal prosecution under applicable law.
1
I certify under penalty of perjury that all statements made herein are true and correct, and that I have not concealed or misrepresented any material fact related to this claim.
*termsandconditions
2
Printed Name of Claimant / Insured
*Full Name
3
Date of Signature
*Date
4
Claimant / Insured Signature
*Signature
How to use this template
Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.
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Applied "Espresso" theme — fonts, colors, and layout already set
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