Settlement and closing
Statement of Loss Template & Example
Last updated 2026-08-03
A statement of loss is the adjuster's arithmetic, laid out so that someone else can check it. It takes each coverage in turn and puts three numbers beside it: the insurance available, the loss sustained, and the amount claimed or recommended. Everything else in the file supports one of those three columns.
The sequence is where practice most often goes wrong. The statement of loss is prepared before the sworn proof of loss is accepted, not after it. It is what the proof of loss is checked against: the adjuster works the numbers, the statement of loss records them and their derivation, and the sworn document the insured executes is then either consistent with it or visibly different for a stated reason. Reverse the order and the statement of loss becomes a transcription of the proof of loss, which means nothing has actually been verified and the file has two documents saying the same unchecked thing.
The worked example below is the statement of loss on a fictional water claim, prepared while a coverage question is still open. It shows an amount recommended, an advance already issued, and a line the adjuster has deliberately declined to fill in.
Jurisdiction
Written primarily against US first-party property practice. Claim handling is regulated state by state — acknowledgment and response deadlines, prompt-payment requirements, adjuster licensing and unfair claims practices standards all differ — and the policy actually issued governs the claim. Where a page cites a statute, model act or regulation, confirm what applies in the state where the loss occurred. Outside the US, treat the structure as transferable and the legal references as not.
Statement of Loss template
Free Word download, no email required. Or open it in Professional Drafter — it lands in your template library, ready to draft against.
When to use this document
- Before a sworn proof of loss is furnished or accepted, so that the figures the insured is asked to swear to have already been derived and checked.
- On any claim with more than one coverage in play, where the deductible interacts with more than one line, or where an advance has already gone out and the settlement has to reconcile to it.
- Not as a substitute for the estimate or the contents inventory. Those carry the itemized detail; the statement of loss carries the totals and shows how they combine.
Worked example
Fictional scenario: the statement of loss on the Harbour Lane water claim, PC-2026-11482, prepared before the sworn proof of loss was executed. One line is left as undetermined on purpose, and the statement goes to the examiner with it still open.
Header
Insured: D. Okonjo. Claim No. PC-2026-11482. Policy No. HO-4471903, term 1 March 2026 to 1 March 2027. Date of loss: reported 14 July 2026, discovered approximately 07:15. Peril: water, escape from a failed supply line. Prepared by R. Calloway on 25 July 2026. Examiner: C. Mendez. This supersedes the statement of loss dated 22 July 2026, which was furnished to the insured with the proof of loss form; it is revised only to record the advance payment issued 24 July 2026 and to update the open items. No figure in Column 1 or Column 2 has changed.
Column 1 — Insurance
From the declarations page in force at the date of loss:
- Coverage A, dwelling:
- $310,000.
- Coverage B, other structures:
- $31,000.
- Coverage C, unscheduled personal property:
- $155,000. Special limits apply to certain categories under the form; none of the property claimed falls within them, the claimed contents being stored books.
- Coverage D, additional living expense:
- actual loss sustained, 12 months.
- All-peril deductible:
- $2,500, applied once to this occurrence.
No limit is approached on any line. No other insurance is in force on this risk.
Column 2 — Loss
Coverage A, dwelling. RCV $16,140, from the estimate dated 22 July 2026: 31 linear feet of drywall wet to 14 inches above slab, removed and replaced to 24 inches; base trim replaced; slab cleaned and dried; utility closet surround, 6 SF, removed and replaced; shelving in the affected run detached and reset. Depreciation $200, applied only to the base trim and the closet surround. ACV $15,940. Neither the drywall replacement nor the cleaning and drying was depreciated.
Coverage B, other structures. Nil. The detached garage was inspected on 18 July 2026 and photographed; no water intrusion was found.
Coverage C, personal property. RCV $2,200, from the inventory the insured provided on 18 July 2026: 14 cartons of stored books, water-stained to varying heights, photographed individually. Depreciation $250. ACV $1,950. Remaining contents on racking approximately six inches above slab were dry and are not claimed.
Coverage D, additional living expense. Nil. The dwelling remained habitable throughout; kitchen, bathrooms and bedrooms were unaffected and the insured has not vacated.
Totals: RCV $18,340, depreciation $450, ACV $17,890.
Column 3 — Claim
Coverage A: amount recommended $15,940 ACV. An advance of $6,500 gross was recommended on 22 July and issued 24 July 2026 as draft 771402; the $2,500 deductible was applied in full to that advance, so the draft issued at $4,000 net. Balance now payable under Coverage A: $9,440.
Coverage B: nil.
Coverage C: amount recommended $1,950 ACV. Nothing yet paid. Balance now payable: $1,950.
Coverage D: nil, none claimed.
Withheld recoverable depreciation: $450 across Coverages A and C, releasable on evidence that the repairs and replacement have been completed, in accordance with the replacement cost provision of the form.
Subrogation recovery: undetermined. The file has been referred to recovery and any recovery would carry the deductible pro rata, but no figure is entered on this line because none exists. It is written as undetermined rather than left blank, since a blank in this column reads as nil.
Reconciliation and totals
Total insurance available on the affected coverages: $496,000 across A, B and C, plus Coverage D on an actual loss sustained basis. No limit is in issue.
- Total loss:
- $18,340 RCV, $17,890 ACV.
- Less deductible:
- $2,500, applied once, taken in full against the advance.
- Amount claimed on an ACV basis:
- $15,390.
- Less prior payments:
- $4,000, draft 771402 dated 24 July 2026.
- Balance now payable:
- $11,390.
Plus withheld recoverable depreciation of $450, contingent on completion.
Cross-check: $9,440 under Coverage A plus $1,950 under Coverage C is $11,390, which ties to the balance above. Indemnity reserve currently stands at $19,000 against an ACV exposure of $17,890; the gap is deliberate and carries the withheld depreciation of $450 plus $660 of margin for supplement, and is documented in the reserve rationale on the file. Expense reserve $2,500.
Open items and basis notes
1. Contents pricing. The inventory was provided 18 July and priced from the insured's own figures; two cartons of reference titles have no comparable listing and were valued conservatively. Requested a receipt or purchase record 18 July and chased by telephone today, 25 July; nothing received yet. R. Calloway.
2. Duration of the water release. Not determined and not estimated. Last occupancy 18:00 on 11 July, discovery 07:15 on 14 July, an interval of roughly 61 hours. There is no water sub-meter on the property, municipal supply is billed quarterly with the next read due September, and there is no alarm or occupancy log. The repeated-seepage provision turns on duration, so the file records the interval and declines to estimate within it. Referred to the examiner 20 July; response outstanding at the date of this statement. C. Mendez.
3. Subrogation. Water heater replaced 11 months before the loss by Feldstrom Plumbing, invoice 20941 dated 3 August 2025. The fitting and line have been retained, tagged and photographed. Referred to recovery 20 July. Any recovery affects the deductible line above but not the amounts recommended. Recovery unit.
4. Supplement. None anticipated at the date of this statement, but the drywall is being opened to 24 inches and further affected material behind the run cannot be excluded until it is opened. Contractor to notify before proceeding beyond the scoped area.
Relationship to the sworn proof of loss
No sworn proof of loss has yet been executed. The form was furnished to the insured on 22 July 2026 under cover of a letter enclosing the statement of loss of that date and the estimate, so that the figures the insured is asked to swear to are the figures already derived and checked here. Acceptance status: outstanding.
When the executed form is returned it will be checked line for line against this statement, and any difference recorded on the file by amount and reason rather than reconciled silently. The item at open item 2 above is expected to remain open at execution; it does not bear on any figure in Column 3, and the proof of loss should say what is known about the timing rather than resolve it.
Section-by-section guide
What each section is for, what a good one contains, and where they typically go wrong.
1.Header
Insured, claim number, policy number, date of loss, peril, adjuster and the date the statement was prepared. The preparation date matters more here than on most documents, because a statement of loss is usually superseded at least once and the file needs to show which version was current when a payment issued.
2.Column 1 — Insurance
The limit applicable to each coverage as written, before anything is subtracted. Take it from the declarations page in force at the date of loss, not from the renewal or the quote. Where a coverage has an internal sublimit that could bind the claim, such as a special limit on a category of personal property or a percentage cap on other structures, show the sublimit on the same line rather than in a footnote, because a limit that binds is the fact most likely to change the settlement.
3.Column 2 — Loss
What the loss actually is, by coverage, on both a replacement cost and an actual cash value basis where the policy distinguishes them. Each figure needs a traceable source: the estimate of a stated date, the contents inventory of a stated date, an invoice number. A figure with no source is the one that gets rebuilt from scratch by the next person to touch the file, and their rebuild will not match yours.
4.Column 3 — Claim
The amount claimed or recommended for each coverage, after the deductible and after credit for anything already paid. This column is the one that becomes a payment instruction, so it should never contain a number that cannot be derived from the two columns to its left. Where a line is undetermined, write undetermined and say what would settle it. A blank in this column reads as zero to everyone downstream.
5.Reconciliation and totals
One block that adds the columns and states the totals in words a reviewer can check in ten seconds: total insurance available, total loss, total claimed, total already paid, balance now payable. If the totals do not tie to the sum of the lines, the statement is not finished. This is also where the deductible is confirmed as applied once, or as applied per the provision, so that nothing later applies it again.
6.Open items and basis notes
Anything that could move a figure, each with an owner and a date. Depreciation method, a supplement expected, an inventory still being priced, a coverage question not yet resolved. This section is what makes the statement of loss reviewable a year later, and it is the one most often left off. A clean statement with no open items on a claim that plainly has some is less credible than an untidy one that lists them.
7.Relationship to the sworn proof of loss
State expressly whether a proof of loss has been furnished, when, and whether the figures on it agree with this statement. Where they differ, record the difference and its amount rather than reconciling silently. This single paragraph is what makes the ordering visible, and the ordering is the thing that gets reversed in practice.
Common mistakes
The failure modes that show up most often when this document is reviewed later.
Preparing the statement of loss after the sworn proof of loss arrives, from the proof of loss.
Nothing has then been verified — the file holds two documents repeating one unchecked set of figures. The statement of loss exists to be the thing the sworn document is checked against.
Leaving an undetermined line blank in the claim column.
A blank reads as nil to the examiner, to the payment system and to whoever reopens the file. Writing 'undetermined' plus what is outstanding costs a line and preserves the item.
Recording a total without recording where each figure came from.
The next person cannot test a number they cannot trace, so they rebuild it, and their rebuild will differ. The source note is what makes the figure survive review.
Applying the deductible on the statement when it was already taken from an advance.
It short-pays the balance by the deductible amount, and it surfaces when the insured adds the drafts together. State once, on the face of the statement, which payment carried it.
Not marking the statement as superseding the earlier version.
Claims settle against whichever version was current when the draft issued. Without supersession dates, nobody can later say which set of figures the payment was made on.
Questions
- Is a statement of loss the same thing as a proof of loss?
- No, and the difference is who is speaking. The statement of loss is the adjuster's working reconciliation of insurance, loss and claim, and it is not sworn. The sworn proof of loss is the insured's own statement of claim, executed under oath and notarized. The statement of loss is normally prepared first and the proof of loss checked against it.
- Does the insured see the statement of loss?
- It varies by carrier and by file. Many adjusters send it, or a version of it, with the proof of loss form so the insured can see how the figures were derived before swearing to them, which reduces the number of forms that come back for re-execution. Whether it goes out is a carrier practice question rather than a rule.
- What belongs on the statement of loss when a coverage question is still open?
- The figures that are determined, and an explicit open item for the one that is not. Describe what is outstanding, who owns it and what would resolve it. Do not enter a provisional number on a line the file cannot support, because provisional numbers stop being provisional the moment somebody downstream copies them.
- How does this relate to what a market conduct examiner looks at?
- Examination standards for claims handling include whether the file is documented well enough to reconstruct the handling and the disposition, which is exactly what a sourced statement of loss provides. The NAIC's record retention model at §6 puts it as maintaining the file so as to show clearly the inception, handling and disposition of each claim, in terms sufficiently clear and specific that events and their dates can be reconstructed.
The blank template
Exactly what is in the Word download, so you can see the structure before deciding whether you want it.
Header
Column 1 — Insurance
- Coverage A — Dwelling: $<limit>
- Coverage B — Other structures: $<limit>
- Coverage C — Personal property: $<limit>, sublimits: <list>
- Coverage D — Loss of use: $<limit or basis>
- Deductible: $<amount>, applied <how>
Column 2 — Loss
- RCV $<amount> — source: <estimate/inventory and date>
- Less depreciation $<amount> — basis: <method, and what was and was not depreciated>
- ACV $<amount>
Column 3 — Claim
- Amount recommended $<amount>
- Less deductible $<amount> (applied to <which line>)
- Less prior payments $<amount> (draft <number>, dated <date>)
- Net now payable $<amount>
- Withheld recoverable depreciation $<amount>, releasable on <condition>
Reconciliation and totals
Open items and basis notes
Relationship to the sworn proof of loss
Download this template
Free Word download, no email required. Or open it in Professional Drafter — it lands in your template library, ready to draft against.
Sources
Related templates
Sworn Proof of Loss Template & Completed Example
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Advance Payment Request Template & Example
An advance payment request that records the amount, the purpose and the coverage it applies against, with a worked example, so the final settlement reconciles without reconstruction.
This page is a documentation aid, not legal advice and not a coverage opinion. Claim-handling requirements vary by state and by policy wording, and a template cannot tell you what your file requires. The worked example describes a fictional loss.