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Insurance Statement of Value

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INSURANCE STATEMENT OF VALUE

Insured / Applicant Information

Insured Name:

Date of Birth (if individual):    Contact Phone:    Email:

Policy / Insurer Information

Policy Number:

Policy Type:

Effective Date:

Expiration Date:

Statement of Values — Itemized Schedule

Provide a complete schedule of property values. List each item or class of property with replacement cost and actual cash value. Use additional pages if necessary and attach supporting documentation.

Location:

Year:

Serial/VIN:

Replacement Cost:

Actual Cash Value:

Repeat item rows as necessary. For convenience, provide summary totals below if itemizing on attachments.

Coverage Selections and Limits

Indicate coverages to be contemplated under the policy. Selection does not modify policy terms; coverage is subject to the actual policy language and underwriting approval.

Building (structure)    Contents / Business Personal Property    Business Interruption

Equipment Breakdown    Inland Marine    Other:

Proposed Limit:

Deductible:

Estimated Annual Premium:

Exclusions and Special Conditions

The following are common exclusions that may apply under the policy: consequential or punitive damages; loss due to wear and tear, gradual deterioration, inherent vice, or mechanical breakdown unless specifically endorsed; loss from war, nuclear hazard, or government seizure except as provided by endorsement; dishonest or fraudulent acts by the insured except as provided by policy. This list is illustrative and not exhaustive. Refer to the applicable policy language for definitive exclusions.

Loss Payee / Mortgagee / Beneficiary Designation

If a loss payee, mortgagee, or other payee is to be named for specific property or policy proceeds, provide complete designation below.

Relationship to Insured:

Percentage of Proceeds:

Certification and Authorization

I certify that the values stated in this Insurance Statement of Value are true and correct to the best of my knowledge and belief. I understand that these values will be relied upon by the insurer for underwriting, premium calculation, and, if applicable, claim settlement. I acknowledge that any material misrepresentation or omission of fact may constitute grounds for denial of coverage, rescission, or adjustment of premiums and limits in accordance with the policy terms and applicable law.

I agree to notify the insurer promptly in writing of any material change in the values, locations, or exposures described herein, including acquisitions or dispositions of insured property, changes in occupancy, or changes in protective safeguards. I authorize the insurer or its representatives to inspect the property and records necessary to verify the information in this statement.

Insured Name:

Signature:

Date:

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What an Insurance Statement of Value Is and when it's used

An Insurance Statement of Value is a formal inventory and valuation record used to document property, equipment, or asset values for an insurance policy. It lists individual items, descriptions, purchase dates, serial numbers, and estimated replacement or actual cash values. Carriers use it to set limits, endorsements, and premiums; policyholders use it to prove value at application, renewal, or claim time. The statement supports underwriting, helps prevent coverage gaps, and forms part of the policy record when attached or referenced by endorsement.

Why an accurate Statement of Value matters

A precise Statement of Value reduces underinsurance risk, speeds claim settlement, aligns premiums with actual exposures, and supports audits and compliance. Insurers rely on the document for underwriting and limits; insureds preserve proof of ownership and value, which can materially affect recovery after a loss.

Why an accurate Statement of Value matters

Core elements to include in a professional Statement of Value

A complete statement balances descriptive detail with verifiable proof; include valuation method, supporting documents, and signatures to ensure it is actionable for underwriting and claims.

Property description

Detailed item descriptions including make, model, serial number, and location to uniquely identify each asset and avoid ambiguity in claims or audits.

Itemized values

Declared replacement or actual cash values per item and a total aggregate value, with currency and rounding conventions explicitly stated for underwriting clarity.

Valuation method

Specify baseline valuation methodology—replacement cost, market value, appraised value, or agreed value—and include the date and source of the valuation.

Supporting documentation

Attach receipts, invoices, appraisals, photos, or serial number lists to substantiate values and reduce underwriting questions or claim disputes.

Effective period

List the effective date and, if applicable, renewal or review dates so insurers know when values were calculated and when reassessment is required.

Certification and signature

A signer declares accuracy, signs, and dates the statement; include signer name, title, and authority to bind the entity for legal clarity.

Who typically completes and relies on this Statement

The document is completed by insureds, brokers, and risk teams to document exposures and support underwriting or claims.

  • Policyholders and business owners who must document assets for coverage and claim support.
  • Insurance brokers and agents preparing submissions or endorsements for carriers.
  • Risk managers and property administrators maintaining updated asset inventories for internal controls.

Accurate completion reduces underwriting questions and speeds claim processing when losses occur; maintain copies in both policy files and operational systems.

Who signs and certifies the Statement

Claims Manager

A claims manager signing a Statement of Value attests that listed items and amounts are accurate to the best of their knowledge. The signer should record title, contact details, and the date to establish authority and permit follow-up during claim adjudication or audits.

Authorized Officer

An authorized officer or owner signs for a business entity, certifying accuracy and authority to bind the company. Include the officer's printed name, title, and a corporate resolution reference if the insurer requests proof of signing authority.

Essential information fields to include

Insured name: Full legal name
Policy ID: Carrier policy number
Item list: Make/model/serial
Declared value: Numeric amount
Valuation date: MM/DD/YYYY format
Attachments: Receipts/appraisals/photos

Step-by-step: completing and submitting a Statement of Value

Follow these sequential steps to prepare, verify, and deliver a complete Statement of Value to the insurer or broker.

  • 01
    Gather records: Collect receipts, photos, and serial numbers for each item.
  • 02
    Enter values: Populate each line using two-decimal numeric format.
  • 03
    Attach proof: Upload supporting PDFs or images in the attachments section.
  • 04
    Sign and send: Sign, date, and submit to the insurer or broker.

Where to send or file the completed Statement

Use the insurer's preferred intake channel; keep copies in both your policy file and internal records for compliance and claims support.

  • Primary carrier: Submit to the insurer's underwriting or policy administration team.
  • Agent or broker: Send a copy to your broker for placement and recordkeeping.
  • Claims department: Provide to claims if related to an active loss or estimate.
  • Internal records: Store a copy in company asset registers or risk systems.

Digital formats and technical considerations for eSubmission

Prepare documents in widely accepted formats and confirm authentication and access needs before eSubmission.

  • Supported formats: PDF, DOCX, HTML, Excel
  • Integrations: Salesforce, NetSuite, Microsoft 365
  • Authentication: Email, SMS, or stronger MFA

Verify the recipient's platform accepts attachments and that signatures preserve an audit trail. Use secure transfer methods and retain a timestamped copy for internal audit purposes.

Common online workflow settings for statements

Configure fields and conditional logic so the form captures necessary detail while reducing entry errors.

Field Configuration
Signature Field Required with audit trail and signer email
Date Field Auto-fill MM/DD/YYYY on signing
Value Field Numeric, two decimals, validation enabled
Attachments PDF receipts required, max file size

Common mistakes that delay underwriting or claims

  • Underreporting values or using rounded totals without item-level backup causes coverage disputes and potential underinsurance issues.
  • Missing invoices, photos, or serial numbers increases time for verification and may lead to claim denials or valuation challenges.
  • Ambiguous item descriptions such as 'equipment' without make or model result in additional insurer queries and slower processing.
  • Failing to date or sign the statement, or using inconsistent names, creates uncertainty about the statement's effective period and authority.

Potential consequences of an incorrect Statement

Underinsurance risk: Partial or reduced claim recovery
Claim denial: Insurer may reject unsupported items
Premium miscalculation: Incorrect pricing or audits
Tax impact: Incorrect asset basis reporting
Legal dispute: Contract or coverage litigation
Compliance breach: HIPAA or regulatory exposure

Practical examples: how Statements of Value are used

Two real-world examples show how different organizations structure and rely on Statements of Value for underwriting and claims.

Commercial Property

A regional retail chain compiled a per-site inventory with serial numbers and invoices to support blanket property limits.

  • The list tied to policy endorsements.
  • At renewal the insurer adjusted limits based on updated totals, reducing audit questions and streamlining future claim documentation for vandalism and equipment loss.

Personal Collection

An individual collector submitted appraisals and high-resolution photos for a valuable art collection to secure agreed-value coverage.

  • Appraised values documented.
  • When a loss occurred, pre-submitted documentation allowed expedited claims processing and payment close to the appraised replacement amounts without lengthy valuation disputes.

eSignature vendor comparison for submitting Statements of Value

Common vendor pricing and feature differences to consider when choosing an eSignature solution for Statements of Value and supporting attachments.

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 trial Varies by plan Varies by plan Varies by plan Varies by plan
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 Statements of Value and eSubmission

Answers to common legal, technical, and practical questions about preparing, signing, and storing an Insurance Statement of Value.


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