Who must sign the statement?

An authorized policyholder representative signs. For corporations, use a named officer or delegated signer; insurers may request proof of delegation or board authorization.

Is notarization required?

Not typically required for most statements of value, but some insurers or specific transactions may request notarization or a certified signature; verify policy terms.

Can I submit electronically?

Yes. Electronic submission is accepted when it meets ESIGN and UETA tests: intent, consent, attribution, and accurate retention capability.

What happens if I underreport value?

Underreporting can lead to coinsurance penalties, reduced claims payments, or premium recalculation; correct promptly and notify the insurer.

Are appraisal reports required?

Appraisals are commonly required for high-value items or when insurer threshold is exceeded; include appraiser credentials and dated reports.

How long should I retain records?

Retain for the policy term plus at least three years; for health-related records retain six years to comply with HIPAA retention guidance.

Electronic Signature
Templates
Insurance
Insurance Statement of Value Document

Insurance Statement of Value Document

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

INSURANCE STATEMENT OF VALUE DOCUMENT

Applicant / Insured Information

Insured Name Mailing Address

Date of Birth:

Contact Phone:

Property / Interest Subject to Insurance

Location of property or risk:

Type of Interest (check all that apply)

Ownership
Leasehold
Mortgagee / Lienholder
Bailee / Custodial

Itemized Statement of Value

Provide the current replacement cost or agreed insured value for each item or property class. Values declared below are exclusive of applicable taxes unless otherwise noted.

Item 1 — Description and Details

Declared Value: $

Serial/ID No.:

Location on Premises:

Item 2 — Description and Details

Declared Value: $

Serial/ID No.:

Location on Premises:

Item 3 — Description and Details

Declared Value: $

Serial/ID No.:

Location on Premises:

Policy Details

Proposed Insurer:

Policy Type:

Policy Number (if existing):

Policy Effective Date:

Policy Expiration Date:

Total Declared Value (sum of above items and other declared property): $

Coverage Selections

Select the coverage forms for which the declared values apply:

Building/Real Property Coverage
Contents/Business Personal Property
Equipment Breakdown / Machinery
Inland Marine / Contractors Equipment
Business Interruption / Time Element
Valuable Papers / Records

Exclusions and Limitations

The insurer may impose exclusions, limits or sub-limits applicable to declared values. Standard exclusions commonly include wear and tear, inherent vice, nuclear hazard, war, and intentional acts. Use the space below to list any additional exclusions or limitations you require to be recorded with this statement of value.

Valuation Basis and Appraisal

Valuation Basis (select one):

Replacement Cost New
Actual Cash Value
Agreed Value / Stated Amount

If valuation is based on appraisal or third-party valuation, provide the appraiser's name and date of appraisal: Appraiser: Date of Appraisal:

Supporting Documentation Checklist

Indicate which supporting documents accompany this Statement of Value:

Recent invoices or receipts
Photographs of items or property
Formal appraisal report
Prior policy declarations
Other documentation (describe below)

Beneficiary / Loss Payee Information

If any third party has a recorded interest or loss payee status, list below. Percentage allocations must total 100% where applicable.

Beneficiary 1 — Name

Relationship:

Percentage:

Beneficiary 2 — Name

Relationship:

Percentage:

Declaration and Certification

By signing below the Applicant certifies under penalty of perjury that (1) the information and values stated in this document are true and correct to the best of the Applicant's knowledge and belief; (2) all material facts that could affect the acceptance of these declared values by an insurer have been disclosed; and (3) any material misrepresentation or omission may result in denial of coverage or rescission of the policy. The Applicant further agrees that the insurer may rely upon the statements contained herein in underwriting, issuing or renewing insurance coverage.

Applicant acknowledges that declared values are binding for the purposes identified in the policy only if accepted in writing by the insurer or evidenced on an insurer's declarations page. This Statement of Value does not in itself bind coverage.

Additional Remarks (optional)

Applicant Name:

Signature:

Date:

By signing above the Applicant certifies that the information provided in this Statement of Value Document is truthful, complete and provided for the purpose of underwriting or adjusting insurance coverage.

What the Insurance Statement of Value Document Is and When It’s Used

An Insurance Statement of Value Document records the declared monetary value of property, assets, or inventory for insurance underwriting and claims purposes. It typically describes the insured item, valuation method, purchase or appraisal date, replacement cost or agreed value, and any supporting attachments such as invoices or appraisal reports. Insurers use the statement to set policy limits, calculate premiums, and determine recoverable amounts after loss. Accurate statements reduce disputes at claim time and help align coverage with actual exposure for commercial and personal property risks.

Why a Clear Statement of Value Matters

A well-prepared Insurance Statement of Value Document improves underwriting accuracy, speeds claim resolution, and reduces the risk of partial or denied claims due to undervaluation. It helps both insureds and underwriters agree on coverage limits and premium basis.

Who Typically Completes and Reviews This Statement

The document is prepared by insured parties or their agents and reviewed by insurance underwriters, brokers, risk managers, and claims adjusters.

Insurance Brokers and Agents — Prepare statements for clients, verify values, and submit to carriers.
Policyholders / Business Owners — Provide invoices, serial numbers, and appraisal reports to substantiate declared values.
Claims Adjusters and Underwriters — Use declared values to set limits, rate premiums, and evaluate claims.

Essential Parts of a Professional Statement of Value

A complete Statement of Value groups identification, valuation, timeframe, and verification into a concise record. Each element supports underwriting decisions and future claim validation.

Insured Identity

Insured name and contact details exactly as on the policy, including policy number and insured location for precise risk mapping.

Property Description

Clear item descriptions, serial numbers, model numbers, quantities, and location; avoid vague labels like "equipment."

Declared Value

Specific dollar amount for each line item and total stated value; indicate whether this is replacement cost, actual cash value, or agreed value.

Valuation Method

State appraisal source, invoice date, dealer quote, or depreciation method used to arrive at declared values and supporting assumptions.

Supporting Evidence

Attach invoices, receipts, appraisal reports, photos, or serial verifications that substantiate each declared value for audit and claims.

Signatures

Authorized signer name, title, signature and effective date to confirm accuracy and authority to represent the insured entity.

Step-by-Step: Completing the Statement of Value

Follow this sequence to prepare and submit a compliant statement that supports underwriting and claims.

01

Gather Evidence: Collect invoices, appraisals, and photos for each item.
02

Complete Fields: Enter names, descriptions, dates, and dollar amounts accurately.
03

Attach Documents: Upload supporting files and clearly label each attachment.
04

Sign and Submit: Obtain authorized signature and forward to insurer or broker.

How to Configure an Online Statement Workflow

Set up an online template to standardize submissions and enforce required fields for every statement.

Template	Create a reusable form template with locked header fields for policy and insured data.
Required Fields	Mark key fields mandatory: declared value, description, valuation date, and signature block.
Conditional Logic	Show appraisal upload only when declared value exceeds a set threshold.
Signer Authentication	Require email verification or SMS code for signer attribution.
Automated Reminders	Enable reminders for unsigned statements and pending attachments.

Routing: Where to Send the Completed Statement

Design routing so the statement reaches underwriting, broker, and claims teams as required.

To Your Broker: Submit initial statement to the broker for review and carrier submission.
To Underwriting: Send final signed copy to the insurer’s underwriting mailbox for policy adjustment.
To Claims: Provide a copy to claims if the statement supports a pending claim.
Records Archive: Store a certified copy in the insured's document repository for audit.

Digital Signing and Delivery Considerations

Choose a platform that supports secure eSignatures, attachments, and audit trails for valuation documents.

File Formats: Accept PDF and DOCX attachments
Integrations: Connect to CRM or document storage
Audit Trail: Record IP, timestamp, and signer actions

Typical Timelines, Deadlines, and Processing Expectations

Insurance timing requirements depend on policy terms and company procedures; plan to meet insurer-specified submission windows.

Policy Change Requests:

Submit 30–60 days before effective change

Underwriting Response:

Underwriters often respond within 7–21 business days

Claim Support:

Provide statement to claims within insurer deadline

Premium Adjustment:

Changes may be prorated from valuation effective date

Audit Period:

Carriers may request documentation up to policy anniversary

Common Preparation Mistakes to Avoid

Undervaluing assets without documentation leads to reduced recovery and disputes during claims, increasing settlement friction and potential litigation.
Using ambiguous descriptions such as "equipment" or "inventory" instead of model numbers and serials complicates verification and may trigger carrier requests for clarification.
Failing to attach invoices or appraisal reports causes repeated follow-ups from underwriters and can delay policy issuance or premium recalculation.
Allowing unauthorized individuals to sign the statement risks rejection; insurers require signatures from named policyholders or delegated authorities.

Consequences of Incorrect or Incomplete Statements

Claim Denial: Carrier may deny claims for material misrepresentation

Coverage Reduction: Insurer can apply coinsurance or limit payouts

Premium Adjustment: Underwriter may increase premiums retroactively

Audit Findings: Insurer audit could require repayment or correction

Regulatory Risk: Consumer-facing errors may trigger state insurance inquiries

Tax Impacts: Inaccurate records complicate tax deductions or bases

eSignature Vendor Comparison for Submitting Statements of Value

Common eSignature platforms vary by price and feature set; signNow is shown first for direct comparison of baseline capabilities important to insurance workflows.

	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	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes (Business Premium)	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Audit Trail	Yes	Yes	Yes	Yes	Yes
Envelope Cap	No cap	100 envelopes/user/year	Varies by plan	Varies by plan	Varies by plan

Frequently Asked Questions About the Insurance Statement of Value Document

Answers to common questions about completion, authentication, and evidence requirements for statements of value.

Need help? Contact support

Who must sign the statement?
An authorized policyholder representative signs. For corporations, use a named officer or delegated signer; insurers may request proof of delegation or board authorization.
Is notarization required?
Not typically required for most statements of value, but some insurers or specific transactions may request notarization or a certified signature; verify policy terms.
Can I submit electronically?
Yes. Electronic submission is accepted when it meets ESIGN and UETA tests: intent, consent, attribution, and accurate retention capability.
What happens if I underreport value?
Underreporting can lead to coinsurance penalties, reduced claims payments, or premium recalculation; correct promptly and notify the insurer.
Are appraisal reports required?
Appraisals are commonly required for high-value items or when insurer threshold is exceeded; include appraiser credentials and dated reports.
How long should I retain records?
Retain for the policy term plus at least three years; for health-related records retain six years to comply with HIPAA retention guidance.

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