Can I submit a statement electronically?

Yes. Electronic submission is generally acceptable so long as the e-signature meets the ESIGN Act and applicable state UETA or ESRA standards for intent, consent, attribution, and retention. Check carrier-specific requirements for authentication strength.

Is notarization required for proof of loss?

Most insurers accept an unsigned or electronically signed statement without notarization, but some policies or state-specific forms may request a sworn affidavit or notarized proof of loss. Verify your policy and state rules before assuming notarization is unnecessary.

How do I correct an error after submission?

Contact the claims adjuster immediately, submit an amended statement marked 'Amendment' with a clear explanation and date, and retain both versions. Timely, transparent corrections reduce dispute risk and support good faith handling.

Who may sign on behalf of an insured?

Only the named policyholder or an authorized representative (agent, attorney-in-fact, or corporate officer with authority) should sign. For delegated signers, maintain written authorization to avoid challenges to signer authority.

What supporting evidence should I include?

Include itemized lists, receipts, repair estimates, photographs, police reports, and any vendor invoices. Clear labeling and chronological organization help adjusters evaluate damages more quickly and accurately.

Are electronically signed statements legally enforceable?

Yes. Electronic signatures are legally binding under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided the signature shows intent, consent, attribution, and the record is reproducible and retained.

Electronic Signature
Templates
Insurance
Insurance Statement of Losses

Insurance Statement of Losses

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

INSURANCE STATEMENT OF LOSSES

Insured / Applicant Information

Insured Name:

Policyholder (if different):

Address

Date of Birth: Phone:

Email

Policy Details

Insurance Company / Carrier

Policy Number: Effective: To:

Policy Coverages / Limits

Deductible: Premium (annual):

Coverage / Peril Selection

Check all perils potentially involved in this loss:

Fire Water damage / flood Wind / Storm Theft / Burglary

Collision (auto) Vandalism Liability claim Other:

Loss Details

Date of Loss: Time of Loss:

Location of Loss Primary Cause or Origin (as known) Detailed Description of Damage and Circumstances Immediate Action Taken (fire department, police, mitigation)

Estimated Total Loss or Damage:

Itemized Damages (Provide all items known to be damaged or lost)

Item 1

Age: Original Cost: Estimated Loss:

Item 2

Age: Original Cost: Estimated Loss:

Item 3

Age: Original Cost: Estimated Loss:

Documentation Checklist

Please indicate which of the following documents accompany this statement:

Photographs of damage Police report Fire department report

Receipts / invoices Repair estimates Inventory list

Exclusions and Acknowledgements

The undersigned acknowledges that coverage under the policy is subject to its terms, conditions and exclusions. Typical exclusions include, without limitation: loss or damage caused intentionally by the insured; wear and tear, gradual deterioration, vermin, or inherent vice; war or nuclear hazard; punitive damages; and any loss excluded by endorsement. Coverage is not admitted by the completion or submission of this statement.

I acknowledge that I have read and understand the exclusions above and that the insurer retains the right to investigate, to determine whether coverage applies, and to adjust the claim in accordance with the policy provisions.

I acknowledge the exclusions and investigative rights described above.

Beneficiary / Payee Information

Primary Payee or Beneficiary (if claim proceeds are to be paid to a party other than the insured)

Relationship to Insured: Percentage of Proceeds:

Declaration and Certification

I declare under penalty of law that the information contained in this Statement of Losses is true, complete and accurate to the best of my knowledge. I understand that any material misrepresentation or omission may constitute insurance fraud and may result in denial of coverage, recovery of payments already made, policy cancellation, or referral for criminal prosecution in accordance with applicable law.

I authorize the insurer, its representatives and contractors to obtain records and information reasonably related to this claim, including but not limited to medical, financial, employment, repair, and loss history records. I further authorize any person or entity in possession of such records to release them to the insurer upon request. I agree to cooperate with the insurer's investigation, to provide truthful statements, and to permit inspection of damaged property.

I understand that payment of any claim may be subject to subrogation rights of the insurer. I agree to assist and cooperate with the insurer in pursuing any subrogation or recovery rights against responsible third parties, including executing assignments, releases and documents required to perfect such rights.

Additional Notes

Applicant Name:

Signature:

Date:

What an Insurance Statement of Losses Records

The Insurance Statement of Losses is a formal claim document completed by a policyholder, authorized representative, or claimant to record property or casualty damage for an insurer. It captures policy identifiers, incident date and location, a detailed narrative of loss, itemized lists of damaged or missing items, estimated values, cause of loss, witness or police report references, and claimant contact information. Carriers and adjusters use this statement to open claims, estimate reserves, investigate liability, and document the factual record for settlement, subrogation, or regulatory review; electronic submission follows ESIGN/UETA requirements when applicable.

Why a Clear Statement Matters for Your Claim

A complete Insurance Statement of Losses produces an auditable record that speeds claim intake, clarifies coverage and valuation, and reduces unnecessary delays or disputes during investigation and settlement.

Who Typically Completes and Reviews This Statement

Typical users include policyholders, claims adjusters, brokers, legal counsel, and loss consultants who complete or review statements during claims handling.

Policyholders and insured individuals reporting loss details, inventories, and initial valuations.
Claims adjusters and examiners documenting liability, damages, estimates, and investigation notes.
Brokers, agents, and attorneys submitting evidence or advocating on behalf of claimants.

Responsibility for completion and final submission depends on policy terms and any agent or adjuster authorizations; verify who may sign or amend the form.

Quick Steps to Prepare and Submit the Statement

Follow these steps to prepare, review, and submit an Insurance Statement of Losses accurately to support timely claims processing.

01

Gather Documents: Collect police reports, photos, receipts, and estimates.
02

Complete Fields: Enter policy info, dates, itemized losses, and witnesses.
03

Attach Evidence: Upload supporting documents and high-quality photos in PDF or JPEG.
04

Sign and Send: Sign, date, and submit via insurer portal or secure email.

Recommended Online Workflow Settings

Configure the online submission workflow to match insurer rules for authentication, file types, notifications, and retention.

Field	Configuration
Authentication	Email link, SMS code, or identity verification
File Types	Accept PDF, DOCX, JPG up to insurer limits
Notifications	Email to claimant, adjuster, and assigned reviewer
Retention	Set automatic retention per insurer policy and legal requirements

How the Statement Moves Through the Claims Process

A completed statement typically routes from the claimant to claims intake, then to an adjuster for investigation and final disposition.

Submit: Send the completed statement to insurer claims intake via portal or secure upload.
Assign: Claims manager assigns an adjuster and opens the claim file.
Review: Adjuster inspects evidence, verifies coverage, and requests additional documentation.
Resolve: Settlement, denial, or subrogation is determined and documented.

Technical Requirements for Electronic Submission

Electronic submission requires secure upload capability, supported file formats, and an audit trail to capture actions and timestamps.

Supported Formats: PDF, DOCX, JPG accepted
Authentication: Email verification, SMS, KBA, or SSO
Audit Trail: Timestamps, IP addresses, and action history

Elements of a Professional Loss Statement

A well-constructed Insurance Statement of Losses presents policy details, a precise incident narrative, itemized losses, valuations, supporting evidence, and an explicit claimant declaration.

Policy Details

Include carrier name, policy number, policyholder name, and effective dates so the claim is matched accurately to the correct insurance contract and coverage period.

Incident Narrative

Provide a clear chronological description of events, root cause, immediate actions taken, and any emergency response to establish context for coverage decisions and investigation.

Itemized Loss List

List each damaged or missing item with make/model, serial numbers when available, purchase dates, and supporting receipts to substantiate ownership and value.

Estimated Valuations

State unit values, depreciation assumptions, and total estimated loss; attach repair estimates, appraisals, or vendor quotes to support amounts claimed.

Supporting Evidence

Attach photos, videos, repair estimates, police reports, and receipts. Clearly label each attachment to make review and verification more efficient.

Claimant Declaration

Include a signed statement attesting to the accuracy and completeness of information, plus date and signer role; note penalties for false statements if applicable.

Security and Record Elements to Include

Encryption: TLS 1.2/1.3; AES-256 at rest

Access Controls: Role-based permissions and SSO

Audit Trail: Immutable logs with timestamps

HIPAA Support: BAA available when required

Retention Policy: Configurable legal retention

Backups: Redundant backups across regions

Common Preparation Mistakes to Avoid

Providing vague descriptions or incomplete itemization that forces repeated follow-up and slows claim resolution.
Submitting low-quality photos or missing receipts that prevent prompt valuation and may lead to denial.
Entering incorrect policy numbers, dates, or claimant names that misroute the claim or trigger identity checks.
Failing to sign, date, or include required authorizations (medical release, police reports) that delay investigation.

Potential Consequences of Errors or Misstatements

Coverage Denial: Incomplete or false facts may result in claim denial

Fraud Allegation: Material misstatements can trigger fraud investigations

Delayed Payment: Missing evidence often prolongs settlements

Incorrect Valuation: Poor documentation yields inaccurate reserve decisions

Statute Issues: Late notice may forfeit coverage under some policies

Subrogation Impact: Weak records can reduce recoveries from responsible third parties

Timing Expectations and Typical Deadlines

Timelines vary by policy and jurisdiction; act quickly and check your policy's notice and proofs-of-loss provisions to avoid forfeiture.

Initial Notice to Insurer:

Report loss as soon as practicable; commonly within 24–72 hours per insurer guidance

Proof of Loss Submission:

Many policies request proof within 60–90 days; verify your specific policy language

Acknowledgment by Insurer:

Insurers typically acknowledge receipt within several business days; timing varies with carrier workload

Investigation Period:

Adjusters may request evidence and inspect within 10–30 business days commonly

Claim Resolution Window:

Settlement or denial often follows investigation; duration varies widely by complexity

eSignature Provider Comparison for Submitting Loss Statements

Comparison of common eSignature options and core attributes relevant to submitting and storing Insurance Statements of Losses; signNow is listed first per comparison guidance.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Yes	Yes	Yes	Yes
Bulk Send	Yes (premium tier)	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes (BAA)	Yes (BAA)	Yes (BAA)	Varies	Varies

Frequently Asked Questions About the Insurance Statement of Losses

Answers to common questions about signing, notarization, corrections, and legal validity when preparing and submitting a statement of loss.

Need help? Contact support

Can I submit a statement electronically?
Yes. Electronic submission is generally acceptable so long as the e-signature meets the ESIGN Act and applicable state UETA or ESRA standards for intent, consent, attribution, and retention. Check carrier-specific requirements for authentication strength.
Is notarization required for proof of loss?
Most insurers accept an unsigned or electronically signed statement without notarization, but some policies or state-specific forms may request a sworn affidavit or notarized proof of loss. Verify your policy and state rules before assuming notarization is unnecessary.
How do I correct an error after submission?
Contact the claims adjuster immediately, submit an amended statement marked 'Amendment' with a clear explanation and date, and retain both versions. Timely, transparent corrections reduce dispute risk and support good faith handling.
Who may sign on behalf of an insured?
Only the named policyholder or an authorized representative (agent, attorney-in-fact, or corporate officer with authority) should sign. For delegated signers, maintain written authorization to avoid challenges to signer authority.
What supporting evidence should I include?
Include itemized lists, receipts, repair estimates, photographs, police reports, and any vendor invoices. Clear labeling and chronological organization help adjusters evaluate damages more quickly and accurately.
Are electronically signed statements legally enforceable?
Yes. Electronic signatures are legally binding under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided the signature shows intent, consent, attribution, and the record is reproducible and retained.

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