Proof Of Loss

Proof of loss is a formal written statement made by you, the insured to the company regarding a claim. You have already given notice to the company of the claim. the company has then determined if the policy responds. If the claim is covered (triggers the policy) then the adjuster will determine how much is to be paid. You will discuss this with the adjuster and come to an agreement. To receive your payment you will be required to sign a document. This document will have to be witnessed and may have to be signed with a Commissioner of Oath seal.

The document used for an automobile loss would look something like this:

Claim No……………………….
Agent or Broker …………………………………..
Insurance Company…………………………………………..
Insured..Name …………………………………………………………
Address ………………………………………………………………..
under Policy Number…………………which is in force until ……………………….. against loss or damage to the vehicle described below which is licensed in the name of and owned by the Insured, according to the provisions of the policy.
Year, Make, Model of Vehicle …………………………………………………………………………………………………………………………………… ……………………………………………………………………..
Vehicle Identification Number …………………………………………………..
License Plate No. & Province…………………………………………………….
Purchased on …………..(day)………………(month)………. 20…………..
from ………………………………………………………… for $………………………..
The loss or damage occurred on the……………………………….. day of ………………………., 20 …………………………, about the hour of …………………….o'clock………………. M
at…………………………………………………………………………………………. …………………………….. ………………………………………………….. …………………………………………………..
caused by …………………………………………………………………………….. …………………………….. ………………………………………………….. …………………………………………………..
Police at…………………………………………………….were notified on the…………………….day of …………………………20………………………..

During the term of the policy there has been no other insurance, valid or invalid, on the vehicle, and no person, firm, or corporation, other than the Insured, has had any interest therein, and there is no lien, chattel mortgage, or conditional sales agreement thereon, except:
………………………………………………………………………….. ………………………. ………………………………………… ………………………… ………………
Goods and Services Tax: The amount claimed should be net of recoverable GST.
Is the Insured registered for GST? ………………..YES ……………….. NO
If the answer is YES, please state: a) Registration Number……………… ……….b) Percent Recoverable………………………… ………………
The total amount of loss or damage so caused is……. ………………………. ………………………………………… ……………………….$………………
Deductible …………………………………………………………… ………………………. ………………………………………… ……………………….$………………
The total amount claimed of the Insurer in respect of the loss or damage is: …………………………………… ……………………….$………………

The loss or damage did not occur through any willful act or neglect, procurement, or connivance of the Insured or this declarant, neither is there included in this claim any amount for anything which was not lost or damaged and owned by the Insured at the time of the occurrence.

Payment of this claim to ……………………………………….. ………………………. ………………………………………… ………………………… ………………
is hereby authorized and in consideration of such payment the Insurer is discharged forever from all further claim by reason of the said loss or damage. All rights to recovery from any other person are hereby transferred to the Insurer which is authorized to bring action in the Insured's name to enforce such rights. All right, title and interest in the vehicle or any part or equipment thereof is hereby transferred to the Insurer only in the event that this claim is based upon the whole value of the vehicle because it has been lost, destroyed or damaged beyond economical repair and the Insured agrees immediately to notify the Insurer in the event of its recovery.

I, ………………………………………………………………………… ………………………. ………………………………………… ………………………… ………………
do solemnly declare that the foregoing claim and statements are to the best of my knowledge and belief true in every particular, and I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath.

DECLARED severally before me at……………………….. ……………………….
……………………………………………………………………….20………………………. ………………….. ………………………… ………………
Date
……………………………………………………………………………………………………. ……………………………………………………………….