Who must sign the statement?

An authorized insured representative or the named policyholder should sign. For corporate policies, include title and contact details. If an agent completes the form, note their relationship and obtain authorization to avoid later verification requests.

Can I submit the form electronically?

Yes. Electronic submission is widely accepted provided the record is reproducible and signer attribution is preserved under ESIGN (15 U.S.C. ch. 96) and UETA. Follow insurer portal or email submission instructions.

Is notarization required?

Most routine loss statements do not require notarization, but sworn affidavits or certain jurisdictional documents may. Check carrier and state requirements before paying for notary services.

What evidence should I attach?

Photographs, receipts, repair estimates, police or incident report numbers, and any prior correspondence. Early documentation reduces disputes and speeds adjustments.

What if I discover additional damage later?

Report supplemental losses promptly to the insurer with documentation. Late or materially different disclosures may require additional investigation and can affect coverage determinations.

How long should I keep claim records?

Retain original statements and supporting documents for at least three years after claim closure; retain HIPAA-related records for six years per 45 CFR §164.530(j) and consult state rules for longer periods.

Electronic Signature
Templates
Insurance
Insurance Statement of New Loss

Insurance Statement of New Loss

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

Insurance Statement of New Loss

Insured / Applicant Information

Insured Name Policy Number Mailing Address

Phone:

Email:

Date of Birth:

Policy Details

Insurer Name:

Policy Type (select all that apply)

Auto Homeowners / Property Commercial Liability Other:

Coverage Limit:

Deductible:

Premium:

Policy Period From: To:

Details of Loss

Date of Loss: Time of Loss:

Location of Loss Cause / Nature of Loss (check all applicable)

Fire Theft / Burglary Collision / Impact Water Damage / Flood Vandalism Other:

Detailed Description of Loss Estimated Amount of Loss

Property / Vehicle / Injuries Involved

Description of Property or Vehicle 1 Estimated Value / Repair Cost Description of Property or Vehicle 2 (if applicable) Estimated Value / Repair Cost Were there any injuries?

Yes No

If yes, provide names and extent of injuries / medical treatment

Authorities / Witnesses / Reports

Was a police report filed? Yes No

If yes, Police Department:

Police Report Number (if available):

Witnesses (names / contact information)

Supporting Documentation Checklist

Photographs of damage/scene Repair estimates Police report Medical reports / bills Proof of ownership / receipts Witness statements Other:

Coverages Claimed

Property Damage Bodily Injury Personal Property Additional Living Expenses / Loss of Use Business Interruption Vehicle Physical Damage (Comprehensive/Collision)

Exclusions and Acknowledgment

I acknowledge that the insurer's policy may exclude coverage for certain losses, including but not limited to wear and tear, gradual deterioration, pre-existing conditions, intentional acts, punitive damages, nuclear hazard, war or acts of war, and certain flood or seismic events where not specifically endorsed. I further acknowledge that submission of this statement does not guarantee coverage or payment.

Acknowledgment I have read and understand the exclusions described above and declare that the information provided in this statement is complete and accurate to the best of my knowledge.

Declaration, Authorization and Fraud Warning

Declaration: I hereby declare that the foregoing statements, answers and representations are true and complete. I understand that any intentionally false or misleading statement made in connection with this claim may constitute insurance fraud and may be subject to civil or criminal penalties under applicable law.

Authorization: I authorize any physician, hospital, employer, insurance company, or other person or organization to release to the insurer or its representatives any records or information reasonably required to investigate or evaluate this claim, including medical records and employment information. A copy of this authorization shall be as valid as the original.

Subrogation and Cooperation: I agree to cooperate fully with the insurer in the investigation and prosecution of any subrogation or recovery action and to execute any documents necessary to effectuate such rights. I further agree not to admit liability or settle with third parties without prior written consent of the insurer.

Consent to Investigation: I consent to investigation of the claim, including interviews, inspections of damaged property and review of relevant records. I understand the insurer may share information with investigators, adjusters, and other parties as reasonably necessary to process the claim.

Additional Remarks

Applicant Name:

Signature:

Date:

What the Insurance Statement of New Loss Is and When It’s Used

An Insurance Statement of New Loss is a standardized claim reporting form used to notify an insurer about a newly discovered loss, incident, or damage that may give rise to a claim. The form documents who suffered the loss, when and where it occurred, the nature and estimated extent of loss, and any immediate mitigation steps taken. Insurers use the statement to open a claim file, start a preliminary investigation, and determine coverage and reserve needs. Many carriers require submission within a policy-specific reporting window to preserve coverage.

Why a Clear Insurance Statement of New Loss Matters

A complete, accurate statement speeds claim setup, reduces disputes, and preserves insurer and insured rights. It provides a documented contemporaneous account for investigation, supports coverage decisions, and helps avoid delays created by incomplete or late notices.

Who Prepares and Signs an Insurance Statement of New Loss

Typical preparers include the insured, an authorized company representative, an agent or broker, and sometimes a vendor or repair contractor documenting initial damage.

Insured party or policyholder — completes factual details about the incident and signs to confirm accuracy.
Company risk manager or authorized rep — prepares business loss statements and coordinates internal documentation.
Agent or broker — may assist with form submission and initial claim intake on behalf of the insured.

The person who signs must be authorized to speak for the insured; mismatched authority can lead to processing delays or requests for additional verification.

Core Sections Found on a Professional Insurance Statement of New Loss

Most statements follow a consistent structure so carriers can quickly locate required facts. Standard sections include claimant and policy identifiers, incident description, date/time/location, property or bodily injury details, witnesses and contact information, estimated loss, actions taken, and supporting attachments such as photos or police reports.

Claimant Details

Policy number, named insured, contact phone and email to link the statement to coverage.

Incident Summary

Concise narrative of what happened, cause if known, and immediate consequences.

Date and Location

Exact date and time (MM/DD/YYYY, HH:MM) plus address or GPS coordinates when available.

Loss Description

Damaged property, injuries, or financial loss with estimated values or ranges.

Witnesses & Authorities

Names, contact details, and police or incident report numbers where applicable.

Attachments

Photographs, invoices, receipts, and official reports appended to support the claim.

Required Fields and Security Considerations

Policy Number: Unique policy identifier

Insured Name: Legal name of policyholder

Incident Date: MM/DD/YYYY

Location: Street, city, state, ZIP

Loss Estimate: Numeric or range

Signature: Signed by authorized party

Step-by-Step: Filling Out the Insurance Statement of New Loss

Follow these steps to prepare a clear, insurer-ready statement and avoid common processing delays.

01

1. Identify Policy: Enter policy number and named insured exactly as shown on the policy.
02

2. Record When/Where: Use MM/DD/YYYY and the specific address; vague timing invites follow-up.
03

3. Describe the Loss: Write a factual, chronological summary focusing on cause and effect.
04

4. Attach Evidence: Include photos, invoices, police reports, and any third-party contact information.

How to Customize the Form for Your Digital Workflow

Configuring a digital template ensures required fields are enforced and attachments are collected consistently across claims.

Field	Configuration
Policy Number	Required text field with exact-match validation
Incident Date	Required date field (MM/DD/YYYY) with max past-date logic
Attachments	Required file upload; accept JPG, PNG, PDF
Authorized Signer	Signer role with email authentication and optional SMS code

Where to Send or File the Insurance Statement of New Loss

Submit the completed statement to the insurer’s claims intake channel specified in the policy — usually an email address, online claim portal, or the agent/broker who placed the policy.

Agent Submission: Send via agent email or portal as instructed
Insurer Portal: Upload to carrier claims portal with claimant ID
Email Intake: Attach PDF with subject line including policy number
Fax or Mail: Use if portal/email unavailable; retain proof of mailing

Distribution and eSubmission Options

Modern carriers accept statements electronically; choose a method that preserves a tamper-evident record and audit trail.

Portal Uploads: Preferred by many carriers for structured intake and immediate claim number assignment
Secure Email: Acceptable when TLS is used; include PDF and certificate of delivery
eSignature: Use compliant e-signature with audit trail (ESIGN/UETA) for signer attribution

Retain confirmation of submission (portal receipt, delivery receipt, or signed PDF with audit trail) as part of the claim file.

Timelines and Deadlines to Know

Timely reporting is often a condition of coverage. Check your policy for specific notice periods and follow insurer instructions for immediate notification.

Policy Notice Window:

Varies by policy; often 'as soon as reasonably possible'

Statutory Prompt Reporting:

State law may require prompt notice for certain risks

Evidence Preservation:

Preserve damaged property and documentation immediately

Follow-Up Deadlines:

Insurer may request estimates or inspections within set days

Claim Closing Timeframe:

Investigation lengths vary; check insurer communications

Common Mistakes That Delay Claims

Missing or incorrect policy number prevents immediate linkage to your coverage and delays assignation of a claim specialist.
Vague incident descriptions lacking dates, locations, or causes trigger insurer follow-up and slow processing.
No supporting evidence (photos, receipts, police reports) causes disputes over loss extent and coverage applicability.
Unsigned statements or signatures by unauthorized individuals lead to requests for verification and processing hold-ups.

Risks from Incorrect or Late Statements

Coverage Denial: Late notice can be a basis for denial if prejudice shown

Reserve Adjustment: Incomplete facts may lead to under-reserving or incorrect payments

Claim Rejection: Material misstatement may justify rejection

Legal Exposure: False statements risk fraud allegations

Delay Costs: Repair or mitigation delays can increase loss amounts

Regulatory Risk: Certain statutorily required notices trigger penalties if missed

eSignature Vendor Pricing and Feature Snapshot for Filing and Signing

Select an eSignature provider that meets your security, compliance, and volume needs. The table compares starting price and core features; signNow appears first per platform ordering rules.

	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	Yes, 7-day trial	No	No	Yes, limited	Yes, limited
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently Asked Questions About the Insurance Statement of New Loss

Answers to common questions about filling, signing, submitting, and retaining the statement. If your insurer provides different instructions, follow the carrier’s guidance.

Need help? Contact support

Who must sign the statement?
An authorized insured representative or the named policyholder should sign. For corporate policies, include title and contact details. If an agent completes the form, note their relationship and obtain authorization to avoid later verification requests.
Can I submit the form electronically?
Yes. Electronic submission is widely accepted provided the record is reproducible and signer attribution is preserved under ESIGN (15 U.S.C. ch. 96) and UETA. Follow insurer portal or email submission instructions.
Is notarization required?
Most routine loss statements do not require notarization, but sworn affidavits or certain jurisdictional documents may. Check carrier and state requirements before paying for notary services.
What evidence should I attach?
Photographs, receipts, repair estimates, police or incident report numbers, and any prior correspondence. Early documentation reduces disputes and speeds adjustments.
What if I discover additional damage later?
Report supplemental losses promptly to the insurer with documentation. Late or materially different disclosures may require additional investigation and can affect coverage determinations.
How long should I keep claim records?
Retain original statements and supporting documents for at least three years after claim closure; retain HIPAA-related records for six years per 45 CFR §164.530(j) and consult state rules for longer periods.

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