Settlement and closing
Sworn Proof of Loss Template & Completed Example
Last updated 2026-08-03
A sworn proof of loss is the only document in a first-party property file that the insured swears to. Everything else in the claim is an assertion; this one is a statement made under oath before a notary, and that single difference governs how it is prepared, how it is corrected, and why the numbers on it have to reconcile to something already in the file before it is signed.
Most proof of loss forms in use run to the same nine recitals in the same order: Time and Origin, Occupancy, Title and Interest, Changes, Total Insurance, Actual Cash Value, Total Loss and Damage, Less Deductible, Amount Claimed. Seven of those track the subject matter the statutory standard fire policy actually enumerates. New York's enactment at Ins. Law §3404 requires the sworn proof to state the time and origin of the loss, the interest of the insured and of all others in the property, the actual cash value of each item and the amount of loss to it, all encumbrances, all other contracts of insurance covering the property, any change in title, use, occupation, location, possession or exposure since issuance, and by whom and for what purpose the building was occupied at the time of loss. California's §2071 is materially the same. The deductible line and the amount-claimed line are form practice rather than statutory text, and they are there for a reason: they turn the last figure into arithmetic instead of assertion. A reviewer reading upward from the bottom should be able to trace every dollar.
The one thing to say plainly, because most blank templates do not: a sworn proof of loss is not edited. A figure crossed out and initialled, or a corrected page swapped in, is a sworn document that no longer matches what was sworn to. The correction is a fresh execution: a new form, signed again, notarized again, usually captioned as an amended proof of loss with the date of the original noted on it. The worked example below is a completed form for a fictional water loss, and it goes out with one question still open, which is the ordinary situation rather than the exception.
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.
Sworn Proof 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
- Whenever the policy condition has been invoked in writing and the insured has been given the form. The statutory standard fire policy forms in New York and California put the proof of loss on a sixty-day clock running from the loss, and many policy forms instead run it from the insurer's written request, so read the form in front of you rather than assuming.
- On any claim where the amount is disputed, where multiple coverages are in play, or where a payment has already gone out as an advance and the file needs one authoritative reconciliation of what has been paid against what is claimed.
- Not as a substitute for the adjuster's own documents. The proof of loss records the insured's sworn claim; the scope, the estimate and the statement of loss record yours, and the proof of loss should agree with them or the disagreement should be visible.
Worked example
Fictional scenario: a completed sworn proof of loss on the Harbour Lane water loss, claim PC-2026-11482, executed while one factual question is still open. The duration of the release has not been determined, the insured's recital says so in terms rather than guessing, and the form is submitted with that gap visible instead of papered over.
Caption and policy identification
To: the insurer under Policy No. HO-4471903, term 1 March 2026 to 1 March 2027. Claim No. PC-2026-11482. Named insured: D. Okonjo. Described location: 118 Harbour Lane, a single-family dwelling. Adjuster of record: R. Calloway. Examiner: C. Mendez. Form furnished to the insured 22 July 2026 with a covering letter requesting completion.
1. Time and Origin
The loss was discovered on 14 July 2026 at approximately 07:15, when the insured returned to the dwelling and found standing water in the hallway. The dwelling was last occupied at approximately 18:00 on Friday 11 July 2026.
The loss originated from the failure of a braided stainless steel supply line to the water heater, which separated at the crimped fitting at the heater end. The exact time at which the line separated is not known to the insured, and no estimate of it is offered here. The insured was absent from the premises for the whole of the interval between last occupancy and discovery, an interval of approximately 61 hours.
2. Occupancy
At the time of the loss the described premises were occupied as the insured's principal residence, by the insured. The premises were unoccupied but not vacant between approximately 18:00 on 11 July 2026 and 07:15 on 14 July 2026, and again between 15 and 17 July 2026 while the insured was out of state. Furnishings and personal property remained in the dwelling throughout. The dwelling has remained habitable since the loss and the insured has not vacated.
3. Title and Interest
Title to the property was vested in D. Okonjo, sole owner, at the time of loss. Harbour County Savings holds a first mortgage under loan number 6620-114. No other person or entity had any interest in the property. Feldstrom Plumbing performed the water heater replacement referred to below but holds no interest in the property.
4. Changes
Since the issuance of the policy there has been no change in the title, use, occupancy, possession, location or exposure of the property, except that the shelving in the hallway closet was raised from the slab to a racking system approximately six inches above slab in April 2026. No structural alteration, no change of use and no rental of any part of the premises has occurred.
5. Total Insurance
The total amount of insurance covering the property at the time of loss was carried under Policy No. HO-4471903 alone, as follows: Coverage A, dwelling, $310,000; Coverage B, other structures, $31,000; Coverage C, unscheduled personal property, $155,000; Coverage D, additional living expense, actual loss sustained for 12 months.
No other insurance was in force on the described property at the time of loss. The insured holds no separate flood policy, no scheduled personal property endorsement and no equipment breakdown coverage on this risk.
6. Actual Cash Value
The actual cash value of the damaged property at the time of loss was $17,890, made up of $15,940 under Coverage A and $1,950 under Coverage C.
The Coverage A figure is the estimated cost to repair the damaged drywall, base trim and closet surround, less depreciation applied to the base trim and the closet surround only; the drywall and the slab cleaning and drying were not depreciated. The Coverage C figure is the depreciated value of 14 cartons of stored books, taken from the inventory the insured provided on 18 July 2026. Both are itemized on the depreciation schedule attached to the estimate.
7. Total Loss and Damage
The whole loss and damage was $18,340 replacement cost value and $17,890 actual cash value, made up as follows: Coverage A, $16,140 RCV and $15,940 ACV; Coverage C, $2,200 RCV and $1,950 ACV. No claim is made under Coverage B; the detached garage was inspected on 18 July 2026 and no water intrusion was found. No claim is made under Coverage D; the dwelling remained habitable and no additional living expense has been incurred.
Itemized on 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, closet surround replaced) and on the contents inventory dated 18 July 2026, both attached.
8. Less Deductible
Less the all-peril deductible of $2,500, applied once to this occurrence. The deductible has already been applied in full to the advance payment issued on 24 July 2026 and is therefore shown here for the arithmetic only; it is not deducted a second time from the balance claimed below.
9. Amount Claimed
The amount claimed under the above numbered policy is $15,390, computed as follows: total loss and damage on an actual cash value basis $17,890, less deductible $2,500, giving $15,390. Of that amount, $4,000 was received by way of advance payment issued 24 July 2026 against Coverage A, leaving a balance of $11,390 now claimed.
The insured reserves the right to submit a supplemental claim for the withheld recoverable depreciation of $450 on completion of repairs, in accordance with the replacement cost provision, and for any additional damage discovered during repair.
Attestation
The insured states that the foregoing is a true and complete statement of all the facts and circumstances concerning the loss so far as they are known to him, that no attempt has been made to deceive the insurer, and that nothing has been concealed or misrepresented. The insured states further that he does not know when the supply line separated and has not attempted to estimate it. It is understood that no waiver of any condition of the policy arises from the taking of this proof of loss, and that the insurer's acceptance or rejection of it remains outstanding at the date of signature.
State, County, signature and notary jurat
State of Delmar, County of Harbour. Subscribed and sworn to before me this 4th day of August, 2026, by D. Okonjo, personally known to me / identified by driver's license.
Signed: D. Okonjo, insured, 4 August 2026. Notary: M. Adeyemi, commission 22-41908, expires 30 June 2029, seal affixed.
File note by R. Calloway, 5 August 2026: this is the first execution. An unsigned draft circulated on 29 July showed the amount claimed at $15,390 with no credit for the advance of 24 July and no balance line, and rather than correct that draft it was destroyed and this form completed and executed fresh. Nothing on a sworn document is corrected in ink.
Section-by-section guide
What each section is for, what a good one contains, and where they typically go wrong.
1.Caption and policy identification
Insurer, policy number, policy term, claim number, named insured and the described location. This block exists so that the sworn document identifies itself without reference to a covering letter, because the two get separated. Confirm the policy number character by character against the declarations page rather than against the claim system, since a transposed digit on a sworn document is a re-execution, not a correction.
2.1. Time and Origin
When the loss occurred and what caused it, in the insured's own account. Two failure modes sit here. The first is a date of loss that silently contradicts the notice of loss or the recorded statement. The second is a cause written with more certainty than anyone actually has — an insured who swears to a cause that the investigation later revises has created a problem that did not need to exist. Where the timing is genuinely unknown, the honest recital says when the damage was discovered and states that the time of onset is not known.
3.2. Occupancy
Who occupied the described premises at the time of loss and in what capacity: owner-occupied dwelling, tenant-occupied, seasonal, vacant, or under renovation. Occupancy is a recital rather than a formality because many property forms treat vacancy and unoccupancy differently from ordinary occupancy, and because a vacancy period is often the fact that explains the rest of the timeline. State what was true, not what is convenient.
4.3. Title and Interest
Who owned the property and who else has an interest in it. Mortgagees, lienholders, contract vendors, life tenants, trusts and co-owners belong here, with loan numbers where they exist, because the interest recited on this form is what drives whose name goes on the draft. An omitted mortgagee is a common reason a settlement check has to be voided and reissued. Note that the statutory standard fire policy asks for encumbrances in terms, so this recital and the encumbrance disclosure are usually answered together.
5.4. Changes
Any change in the title, use, occupancy, possession, location or exposure of the property since the policy was issued. Most of the time this recital is a single word, and it is still worth pausing on: a converted garage, a new short-term rental arrangement, a tenant who moved in, or a building materially altered since inception all belong here. The recital asks about changes since issuance, not since the loss.
6.5. Total Insurance
Every policy covering the property at the time of loss, not merely the one being claimed against. List the insurer, the policy number and the applicable limits, and state affirmatively that no other insurance was in force if that is the case. This recital is what makes any later contribution or other-insurance question answerable from the file rather than from a fresh investigation, and it is the one insureds most often complete from memory.
7.6. Actual Cash Value
The actual cash value of the property at the time of loss, stated by coverage. ACV is measured differently from state to state. California defines it by statute as the cost to repair, rebuild or replace less a fair and reasonable deduction for physical depreciation, with the depreciation restricted to components that normally require repair or replacement during the structure's useful life, while other states apply a broad-evidence rule instead. Do not write a general rule into this recital. Write the figure, and say on the face of the document which method produced it and where the supporting schedule lives.
8.7. Total Loss and Damage
The whole loss and damage, before any deduction. Attach the estimate and the contents inventory rather than restating them; the recital carries the totals and the attachments carry the detail. Keep the replacement cost and actual cash value figures visibly distinct here, because a proof of loss claiming replacement cost on a policy that pays actual cash value until repairs are complete is the single most common reason one comes back.
9.8. Less Deductible
The deductible, the amount of it, and how many times it applies. Say which occurrence it is applied to and note it if it has already been taken out of an advance payment, because a deductible applied twice, once against the advance and once against the balance, is a reconciliation error that surfaces months later when the insured adds up the drafts.
10.9. Amount Claimed
The bottom line, and it should be arithmetic: total loss and damage, less deductible, less any amount already paid, equals the amount now claimed. Show the subtraction on the face of the form. Where an advance has been issued, credit it here by amount and date rather than leaving the reader to find the draft. A proof of loss whose final number cannot be derived from the recitals above it is the version that gets returned.
11.Attestation
The insured's sworn statement that the foregoing is true, that nothing has been concealed, and, in most forms, an acknowledgment that no representation by the insurer has waived any policy condition. This paragraph is why the document exists. Do not paraphrase whatever wording the form in front of you carries, and do not let an insured sign an attestation covering figures they have not read.
12.State, County, signature and notary jurat
The venue block, the insured's signature, and the jurat by which the notary certifies that the document was signed and sworn to in their presence. Two practical points. The signature belongs on the form after the figures are final, not before. A form signed in advance and completed afterward is not what it says it is. And the jurat wording, the identification requirement and whether a personal appearance can be satisfied remotely are all set by the law of the state where the signing happens, so leave the notarial certificate to the notary rather than pre-filling it.
Common mistakes
The failure modes that show up most often when this document is reviewed later.
Correcting a figure on an executed proof of loss by striking it through and initialling it.
The document then attests to something other than what was sworn. The fix costs a second notary appointment and nothing else, and skipping it produces a sworn instrument whose face contradicts the file.
Claiming replacement cost on a form where only actual cash value is presently payable.
It reads as an overstated claim rather than a sequencing error, and it usually comes back for re-execution. State both figures and show which one the amount claimed is derived from.
Omitting the mortgagee or lienholder from the title and interest recital.
The interest recited on the form drives whose name goes on the draft. A check issued without a mortgagee that should have been named gets voided and reissued, and the insured waits again.
Taking the deductible twice — once from the advance and once from the balance.
It surfaces when the insured adds the drafts together, usually months later, and it looks like short payment rather than arithmetic. Say on the face of the form where the deductible was applied.
Letting an insured sign a blank or partly completed form to be filled in afterward.
The jurat certifies that what appears on the page was sworn to. A form completed after signature is not that, and the whole evidentiary point of the document is lost.
Writing a confident cause into Time and Origin when the investigation has not established one.
The insured is the one swearing to it. If the file later revises the cause, the sworn recital is the sentence that gets quoted back, and it was avoidable by recording what is known and saying that the rest is not.
Questions
- How long does the insured have to submit a sworn proof of loss?
- It depends on the policy form and the state, and the difference is not small. The statutory standard fire policy enacted in New York at N.Y. Ins. Law §3404 and in California at Cal. Ins. Code §2071 puts the proof of loss at sixty days after the loss unless the insurer extends it in writing, while many modern homeowners forms instead run the period from the insurer's written request. Some states impose their own period by statute. Read the condition in the form in front of you and check your state's provision rather than assuming the sixty-day version applies.
- Does taking a proof of loss waive anything?
- Non-waiver language is usually printed on the proof of loss form itself, which is why that sentence appears in the attestation above. Be careful about where you say it comes from: the statutory standard fire policy's own non-waiver clause, as enacted in New York at Ins. Law §3404, is written about requirements and proceedings relating to appraisal and to the examination provisions, not about the proof of loss condition. Whether any particular course of conduct affects a defense is a legal question that turns on state law and on the facts, and it is not something a template can answer.
- What if the insured disagrees with the adjuster's figures?
- The proof of loss records the insured's sworn claim, not the adjuster's estimate, so the insured may state their own figures. The practical consequence is that the file then contains two numbers, and the file should show why: the estimate, the proof of loss, and a note explaining the difference. A visible disagreement is a normal file. A proof of loss silently signed against figures the insured never accepted is not.
- How does the proof of loss interact with the insurer's decision clock?
- In the NAIC's model regulation the acceptance-or-denial period runs from receipt of a properly executed proof of loss. Model 902 §7(A) recommends 21 calendar days, and states that have adopted the model set their own count in their own regulation. Because the models bind nobody, the operative deadline is always the state's own text; use a comparison chart only to find the citation, then read the provision itself.
The blank template
Exactly what is in the Word download, so you can see the structure before deciding whether you want it.
Caption and policy identification
1. Time and Origin
2. Occupancy
3. Title and Interest
4. Changes
5. Total Insurance
- Coverage A — Dwelling: $<limit>
- Coverage B — Other structures: $<limit>
- Coverage C — Personal property: $<limit>
- Coverage D — Loss of use / additional living expense: $<limit or basis>
- Other policies covering the same property: <insurer, number, limit, or 'none'>
6. Actual Cash Value
7. Total Loss and Damage
8. Less Deductible
9. Amount Claimed
Attestation
State, County, signature and notary jurat
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
- N.Y. Insurance Law §3404 — standard fire policy (statutory text)
- Cal. Insurance Code §2071 — standard form fire policy
- Cal. Insurance Code §2051 — actual cash value
- NAIC — Unfair Property/Casualty Claims Settlement Practices Model Regulation (Model 902, 1991 amendment, July 1997 print)
- NAIC — Market Conduct Record Retention and Production Model Regulation (Model 910, January 2004)
- NAIC — Chart MC-50: Claims Settlement Provisions (Spring 2024)
Related templates
Statement of Loss Template & Example
The three-column statement of loss, insurance, loss and claim, with a filled-in example and the sequence that matters: it is completed before the sworn proof of loss is accepted.
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.