Homepage Official Florida Proof Loss Template
Overview

In the landscape of insurance claims within Florida, the Sworn Statement in Proof of Loss holds a significant place, encapsulating the essence of the claimant's declaration regarding the details and magnitude of their loss. This document, governed by Section 817.234 of the Florida Statutes, serves not only as a formal assertion of the damages or losses incurred but also plays a pivotal role in the insurance claim process, acting as a deterrent against fraudulent claims through its stern warning against the submission of false, incomplete, or misleading information—a felony of the third degree, subject to severe penalties under Sections 775.082, 775.083, or 775.084 of the Florida Statutes. Beyond its legal implications, the form requires detailed inputs ranging from policy particulars, including the amount of policy at the time of loss and the agent's details, to comprehensive descriptions of the loss event, including the date, time, and cause of loss, alongside a disclosure of any other interests or liens on the property involved. Moreover, it prompts the claimant to report any changes in title or occupancy of the property during the policy term, other policies that may cover the loss, and an itemized account of the loss and damage incurred with respect to buildings, contents, additional living expenses (ALE), or rental loss receipts, culminating in the total amount claimed. This sworn statement underscores the integrity of the claim process, ensuring that every claim forwarded to an insurer is backed by the truthful and accurate representation of events as known to the insured, thereby reinforcing the framework within which insurance operates in Florida.

Example - Florida Proof Loss Form

SWORN STATEMENT IN PROOF OF LOSS

PURSUANT TO S. 817. 234, FLORIDA STATUTES, ANY PERSON WHO, WITH THE INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER OR INSURED, PREPARES, PRESENTS, OR CAUSES TO BE PRESENTED A PROOF OF LOSS OR ESTIMATE OF COST OR REPAIR OF DAMAGED PROPERTY IN SUPPORT OF A CLAIM UNDER AN INSURANCE POLICY KNOWING THAT THE PROOF OF LOSS OR ESTIMATE OF CLAIM OR REPAIRS CONTAINS ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION CONCERNING ANY FACT OR THING MATERIAL TO THE CLAIM COMMITS A FELONY OF THE THIRD DEGREE, PUNISHABLE AS PROVIDED IN S. 775.082, S.775.803, OR S.775.084, FLORIDA STATUTES.

$__________________________________________

________________________________________________

AMOUNT OF POLICY AT TIME OF LOSS

POLICY NUMBER

___________________ _______________________

________________________________________________

DATE ISSUED

DATE EXPIRES

AGENT

1.Name of Insurance Company:____________________________________________________________________________

2.

Claim Number: ___________________________

3.

Named Insured(s)______________________________

4.

Date of Loss: _____________________________

5.

Time of Loss: _________________________[a.m./ p.m]

6.Cause of Loss: The cause and origin of the said loss were:______________________________________________________

________________________________________________________________________________________________________

7.Title and Interest: [My/Our] Interest in the property involved at the time of loss was as follows: ____________________

_____________________________________________________________________________________________

8.Names of Mortgages/Lienholders :________________________________________________________________________

________________________________________________________________________________________________________

Other than the insureds and any and all loss payees indicated in the policy of insurance, there are no other persons who have an interest or lien in the property involved, except for above named mortgage or lienholders, except:

________________________________________________________________________________________________________

9.Other policies of insurance which may cover the loss: ________________________________________________________

10.Describe changes in title to the property during the policy term or changes in occupancy of property during policy

term:___________________________________________________________________________________________________

11.Total Insurance: The Total amount of insurance upon the property described by this policy was, at the time of loss $__________________________, as more particularly specified in the policy declarations sheet.

12.The Actual Cash Value of said property at the time of loss was: $_______________________________________________

13.Loss and Damage: The specifications of damaged buildings, if applicable, are contained in the attachments hereto; The specifications of damaged contents, if applicable, are contained in the attachments hereto; If applicable, ALE or rental loss receipts are attached hereto. The loss and damage is as follows:

Building:

$________________________

 

Other Structure(s)

$________________________

 

Contents

$________________________

 

Adjusted Living Expenses ("ALE")

$________________________

 

The Whole Loss Total:

$________________________

 

Deductible:

$________________________

 

Whole Amount Claimed Minus Deductible

$________________________

The loss did not originate by any act, design, or procurement on your part; no property has been concealed, and no attempt to deceive the said company as to the extent of the loss has been made. The undersigned certify that the statements and information contained herein with respect to the loss reported are accurate and truthful to the best of [his/her/their] knowledge and belief.

_________________________________________

____________________________________________

Signature of Insured

Signature of Insured

Print Name:______________________________________

Print Name ___________________________________

State of Florida, County of ______________

Sworn to and subscribed to before me on this ________ day of ____________________________________ , 20 _______ .

 

Personally known, or

Notary Public, State of Florida_________________________

Produced :_____________________________________

File Specifications

Fact Number Fact Detail
1 The form is used for presenting a claim of loss to an insurance company in Florida.
2 Governing law for the form is S. 817.234, Florida Statutes.
3 Filing a false, incomplete, or misleading claim is a felony of the third degree under this statute.
4 Penalties for violations can be found in S. 775.082, S.775.083, or S.775.084 of the Florida Statutes.
5 The form requires detailed information including policy number, date of loss, and cause of loss.
6 Claimants must disclose any other policies that may cover the loss and any changes in property title or occupancy.
7 The form must be signed by the insured parties and notarized in the State of Florida.

Instructions on Filling in Florida Proof Loss

Filling out the Florida Proof of Loss form requires careful attention to detail and accuracy in reporting. This document is a vital component of the insurance claim process, where the insured party details the loss they have experienced. It's important to keep in mind the legal implications of submitting this form, as any attempt to deceive or defraud can lead to serious consequences, including felony charges. By following the steps listed below, you can ensure that your form is complete, accurate, and ready for submission. This not only streamlines the claim process but also helps in safeguarding against potential legal issues.

  1. Read the warning statement at the top of the form carefully to understand the legal implications of submitting false, incomplete, or misleading information.
  2. Enter the Amount of Policy at Time of Loss and the Policy Number in the designated spaces.
  3. Fill in the dates the policy was Issued and Expires, along with the Agent’s information.
  4. Write the Name of Insurance Company at the top of the document.
  5. Provide the Claim Number in the space given.
  6. Specify the Named Insured(s), ensuring to list all parties covered by the insurance policy.
  7. Indicate the Date and Time of Loss, making sure to mark a.m. or p.m. appropriately.
  8. Describe the Cause of Loss in detail, ensuring to explain how the loss occurred.
  9. Detail your Title and Interest in the property at the time of loss, including any joint owners or stakeholders.
  10. List any Names of Mortgagees/Lienholders, if applicable.
  11. Mention any Other Policies of Insurance that may cover the loss.
  12. Describe any Changes in Title or Occupancy of the property during the policy term.
  13. Enter the Total Insurance covering the property as specified in the policy declarations sheet.
  14. State the Actual Cash Value of the property at the time of loss.
  15. Detail the Loss and Damage, including breakdowns of building, other structures, contents, and any Adjusted Living Expenses (ALE) or rental loss receipts, attaching additional pages if necessary. Include the total loss amount, deductibles applied, and the whole amount claimed after the deductible.
  16. Affirm that the loss was not caused by any fraudulent act on your part, that no property has been concealed, and that there has been no attempt to deceive the insurance company regarding the extent of the loss.
  17. Sign and print your name under the Signature of Insured section. If there's more than one insured, ensure that all parties sign and print their names.
  18. Complete the Sworn Statement section with the date and your location (State of Florida, County of ______________).
  19. Have the form Notarized by a Notary Public, ensuring they affix their seal and fill their details accordingly.

After completing these steps, review the form to ensure all information is accurate and no section has been overlooked. Submitting a comprehensive and factual proof of loss form is crucial in facilitating a smooth claims process, resulting in a timely and fair settlement of your claim.

Understanding Florida Proof Loss

What is a Florida Proof of Loss form?

A Florida Proof of Loss form is a document filed by an insured individual to their insurance company, outlining the details and extent of damage they have suffered. It's a sworn statement that includes information about the policy amount at the time of loss, date and cause of the loss, description of the damaged property, and the total amount claimed. This document is crucial for processing insurance claims related to property loss in Florida.

Why do I need to complete a Florida Proof of Loss form?

Completing a Florida Proof of Loss form is a necessary step in the claims process. It provides your insurance company with essential information about the loss you've experienced. This form helps the insurer evaluate the damage and determine the amount of compensation you're entitled to under your policy. Without this form, processing your claim could be delayed or denied.

What happens if I include false information in the Proof of Loss form?

Including false, incomplete, or misleading information in your Proof of Loss form is a serious offense. Under Florida Statutes, anyone who knowingly supplies false details in support of an insurance claim commits a felony of the third degree. If found guilty, the individual can face penalties as provided in sections 775.082, 775.803, or 775.084 of the Florida Statutes, including fines and imprisonment.

What information do I need to provide on the Florida Proof of Loss form?

You are required to provide specific details in the form, including the amount of policy at the time of loss, policy number, claim number, the insured individual's name, date and cause of the loss, interest in the damaged property, names of mortgage or lienholders, other insurance policies that may cover the loss, and a detailed list of the loss and damages with the total amount claimed.

How do I calculate the total loss and damage on the form?

To calculate the total loss and damage, you will need to specify the costs associated with damaged buildings, other structures, contents, and additional living expenses (ALE) or rental losses, if applicable. Attach receipts and detailed specifications of all damages. The whole loss total is then reduced by any applicable deductible to determine the whole amount claimed.

Can I have someone fill out the form on my behalf?

While you may seek assistance in gathering the necessary information and understanding what needs to be included, the form must be sworn to and signed by you, the insured. It is a legal document, and providing accurate and truthful information is crucial. However, you may consult with a legal advisor or claim professional for guidance.

What should I do if I discover additional damages after submitting my Proof of Loss form?

If you find additional damages after your initial submission, you should immediately notify your insurance company. Depending on the situation, you may be asked to submit an amended Proof of Loss form or provide additional documentation to support the new claims. It's important to communicate openly with your insurer to ensure your claim is accurately processed.

Where do I submit my completed Florida Proof of Loss form?

Your completed Florida Proof of Loss form should be submitted to your insurance company. The specific address or contact details where the form should be sent can usually be found on your insurance policy documents, or you can contact your insurance agent for guidance. Ensure that you keep a copy of the form and all attachments for your records.

Common mistakes

Completing the Florida Proof of Loss form accurately is pivotal for policyholders pursuing insurance claims after experiencing property damage. However, individuals often encounter pitfalls that can complicate their claims process. Recognizing and avoiding these mistakes can expedite claim resolution and ensure a fair assessment by the insurer.

  1. Providing Inaccurate or Incomplete Information: One of the most common errors involves submitting false, incomplete, or misleading particulars. The form clearly states that presenting incorrect information with the intent to defraud or deceive an insurer or insured is a criminal offense under Florida law. Accuracy is paramount, not only to fulfill legal obligations but also to ensure the legitimacy and success of the claim.

  2. Omitting Relevant Attachments: Failure to include all necessary attachments, such as the specifications of damaged buildings or contents and, if applicable, ALE (Adjusted Living Expenses) or rental loss receipts, can result in underpayment or denial of the claim. These documents offer a detailed breakdown of the loss and substantiate the claim amount. Providing comprehensive documentation avoids delays and ensures a thorough evaluation by the insurance company.

  3. Overlooking Updates in Property Status: Claimants occasionally neglect to update changes in the title or occupancy of the property during the policy term. This oversight can lead to discrepancies in the claim, as the insurance coverage might have terms specifically related to these factors. Accurately reporting any changes helps prevent disputes about the claim's validity and the extent of coverage.

  4. Incorrectly Calculating the Claim Amount: Incorrectly calculating the Total Loss or the Whole Amount Claimed Minus Deductible is another frequent misstep. This calculation must reflect an accurate evaluation of the loss, considering the actual cash value or replacement cost, as applicable, minus any deductible. Miscalculations can either inflate the claim, leading to potential legal issues, or undersell the loss, resulting in inadequate compensation. Professionals, such as appraisers or contractors, can provide reliable estimates to ensure accuracy.

Comprehension and careful completion of the Florida Proof of Loss form is essential. By avoiding these mistakes, policyholders can streamline the claims process, fostering a clearer, more efficient path to recovery.

Documents used along the form

When filing a Florida Proof of Loss form, it's crucial to understand that this document is rarely submitted in isolation during the insurance claims process. The completion and submission of a Proof of Loss form are typically accompanied by several other documents. These documents collectively support your claim, providing comprehensive details and evidence to the insurance company. Here, we describe six common forms and documents often used alongside the Florida Proof of Loss form.

  • Insurance Policy: This document outlines the coverage details, including what damages are covered, policy limits, and any deductibles. The insurance policy is fundamental as it establishes the framework within which the claim operates.
  • Photographic Evidence: Photos or videos documenting the extent of the damage can be vital. This visual proof complements the Proof of Loss form, offering a clear depiction of the damage for which compensation is sought.
  • Police or Fire Reports: If the loss involves theft, vandalism, or fire, official reports from the police or fire department can serve as critical evidence to support your claim. These reports can provide an authoritative summary of the events leading to the loss.
  • Receipts for Damaged Property: Providing receipts or appraisals for damaged or lost items can help establish their value, making it easier for the insurance company to assess the compensation due.
  • Repair Estimates: Detailed estimates from contractors or repair shops offer a third-party viewpoint on the extent of the damage and the expected costs of repairs, which can help in quantifying the claim.
  • Correspondence with the Insurance Company: Keeping a record of all communications between you and your insurance provider is beneficial. This documentation can include emails, letters, and notes from phone conversations, helping to track the progress of your claim.

Navigating through the aftermath of a loss can be challenging, but understanding the kind of documentation needed to support your Proof of Loss can streamline the process. Each supportive document plays a crucial role in painting a complete picture of the incident for the insurance adjuster, which can ultimately aid in the swift processing and approval of your claim. Remember, thoroughness and accuracy in your documentation are key to a successful claims process.

Similar forms

  • Property Damage Report: Both documents require detailed information about the damage incurred, including the date, time, and cause of the damage. They are essential for the claims process, serving as formal documentation to support the claimant's request for compensation under an insurance policy.

  • Homeowner's Insurance Claim Form: This is similar to the Proof of Loss form in that it often requires the insured to list damages to their property, provide an estimated cost of repairs, and declare the value of lost or damaged items. Both forms are used to initiate a claim, and might also include declarations about other insurance policies in effect that could cover the loss.

  • Auto Insurance Claim Form: Similarities include the need for policyholders to provide detailed information about the incident (e.g., date, time, cause of loss), and to submit estimates for repair or confirmation of losses. These forms are foundational for the insurance company's assessment and approval process for reimbursement.

  • Health Insurance Claim Form: While serving a different type of insurance, the structure of providing detailed incident information, supporting documents, and a sworn statement regarding the truthfulness of the information provided mirrors that of the Proof of Loss form.

  • Bailment Agreement: In this document, one party takes possession of another's property under the condition that it will be returned or accounted for. Like the Proof of Loss, a Bailment Agreement often includes detailed descriptions of the property and conditions of its handling, akin to the specifications of damaged or lost items on a Proof of Loss form.

  • Police Report: Required for many insurance claims, a police report provides an official account of an incident involving loss or damage. The level of detail expected in such reports, including specifics about what occurred, who was involved, and the outcome, closely aligns with the comprehensive details required in a Proof of Loss form.

  • Business Interruption Insurance Claim Form: This document shares similarities with the Proof of Loss form where businesses must detail the loss (such as income, time frame of interruption, and causation), akin to detailing property damage or loss, to substantiate a claim for lost revenues due to unforeseen events.

Dos and Don'ts

When you fill out the Florida Proof of Loss form, there are certain things you should do and others you should avoid to ensure the process is smooth and your claim is processed efficiently. Here's a concise guide:

Things You Should Do:

  • Provide accurate information: Make sure all the information you include on the form is true and correct to the best of your knowledge. Incorrect or misleading details can lead to delays or denial of your claim.
  • Include detailed descriptions: For the cause of loss, damage, and property involved, provide detailed and clear descriptions. This helps in the assessment of your claim.
  • Attach necessary documentation: If the form mentions attaching any documents, such as receipts or an inventory of damaged property, ensure you attach these. They are crucial for verifying the details of your loss.
  • Review the form for completeness: Before submitting, review all sections of the form to ensure you haven't missed any required information.
  • Sign and date the form: Your signature certifies that the information provided is truthful. Ensure both the insured sign if applicable and date the form correctly.
  • Keep a copy for your records: It's always a good idea to keep a copy of the completed form and all attachments for your own records.

Things You Shouldn't Do:

  • Do not provide false information: Intentionally providing false or misleading information on a Proof of Loss can have serious legal consequences, potentially including felony charges.
  • Avoid guessing: If you're unsure about certain details, it's better to verify them first rather than guess. Incorrect information can complicate the claim process.
  • Don't skip sections: Each section of the form is important. Skipping parts of the form can result in delays or even denial of your claim.
  • Don't underestimate damages: Provide a full description and valuation of your loss. Underestimating can lead to insufficient coverage.
  • Don't rush through the form: Take your time to fill out each section accurately. Rushing can lead to mistakes or omissions.
  • Avoid delaying: Submitting your Proof of Loss in a timely manner is critical. Delaying can affect the processing and potentially the outcome of your claim.

Filling out the Florida Proof of Loss form carefully and accurately is crucial to the success of your insurance claim. By following these guidelines, you can help ensure a smoother process.

Misconceptions

When dealing with insurance, terms and processes can often seem overwhelming. This is especially true for the Florida Proof of Loss form - a crucial document in the claims process. There are common misconceptions about this form, which can lead to confusion. Let’s clear up some of these misunderstandings:

  • It’s just a formality: Many believe that the Proof of Loss form is simply a formality and doesn’t require much attention. However, this document is a sworn statement that officially notifies your insurance company of the amount of loss you are claiming. It is a critical part of your insurance claim, and inaccuracies or omissions can significantly impact the outcome of your claim.
  • It doesn’t need to be detailed: Another misconception is that general information is enough when completing the form. On the contrary, providing detailed information about the loss, including the date, time, and cause of the loss, as well as a detailed description of the damaged property, is essential. The more specific you are, the smoother the claims process will be.
  • Only the insurance adjuster fills it out: Some policyholders think that the insurance adjuster is responsible for completing the Proof of Loss form. While adjusters can assist in the claims process and even help in determining the value of lost items, it is ultimately the responsibility of the policyholder to ensure that the form is accurately completed and submitted.
  • There’s no deadline for submission: It’s a common mistake to assume that you can submit the Proof of Loss form at any time. Insurance policies often have strict deadlines for when this form must be submitted following a loss. Failing to meet these deadlines can result in a denied claim, so it’s important to act promptly and attentively.
  • Any version of the form will do: People often think that any Proof of Loss form will work. However, it's important to use the specific form provided by your insurance company, as it may contain particular stipulations or sections that are unique to your policy or coverage. Using the incorrect form can result in processing delays or even claim denial.

Understanding the importance and requirements of the Florida Proof of Loss form is the first step towards a successful insurance claim. It’s not just another piece of paperwork; it’s a critical part of your claim that requires thorough and accurate completion. Always read your insurance policy carefully and seek clarification from your insurer if you have any doubts. By debunking these misconceptions, you are better prepared to navigate the claims process with confidence.

Key takeaways

Here are seven key takeaways about filling out and using the Florida Proof of Loss form:

  • It is crucial to ensure that all information provided on the Florida Proof of Loss form is accurate and truthful to avoid any allegations of fraud, which is a serious offense under Florida Statutes.
  • The form requires detailed information about the insurance policy, including the amount of policy at the time of loss, policy number, date issued, and date expires.
  • Identification of the named insured(s) along with the claim number must be clearly provided.
  • The form necessitates specifics about the loss, including the date and time of the loss, as well as a comprehensive description of the cause of loss.
  • Details regarding any changes in title or occupancy of the property during the policy term are needed. This helps in determining if any such changes may affect the claim.
  • A complete inventory of the loss and damage, including actual cash value and the total claimed amount minus deductible, is required for processing the claim.
  • The form must be signed by the insured(s) and notarized, which serves as a sworn statement to the truthfulness and accuracy of the information provided.

It is important to fill out this form with due care and attention to detail, as it forms the basis of the insurance claim. Providing false, incomplete, or misleading information not only jeopardizes the claim but may also result in legal consequences.

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