Fillable Printable Blank Affidavit of Loss Form

Blank Affidavit of Loss Form

Claim #______________________________________

AFFIDAVIT OF LOSS

“Any person who, with the intent to defraud of knowing that he is facilitating a fraud against an insurer, submits an

application or files a claim containing a false or deceptive statement is guilty of insurance fraud.” All questions must be

answered and the document signed and notarized or this affidavit may be rejected.

1. Name:___________________________ Home phone:__________________________________

Address:_________________________ Work phone:___________________________________

________________________________ Driver’s License # & State:________________________

Employer:______________________________________________________________________

Address:_______________________________________________________________________

______________________________________________________________________________

A photo copy of your driver’s license or other acceptable identification is required to be sent along with this

affidavit to prevent possible fraudulent activity on your account and to ensure that only you are able to file a claim.

Names of other people who were with you when the phone was lost:

• Name:_________________________ Phone #_____________________ Email:______________

2. Date of Loss:_________________________________________Time:__________________am/pm

Specific location where the wireless device was lost:___________________________________

Reason the device was left at this location:___________________________________________

Name of your device locator/tracking service:________________________________________

Has the device been locked and wiped clean?_________________________________________

When was the loss discovered:_________________ By whom?__________________________

Do you suspect the device was stolen: YES NO

If the device is suspected to be stolen, have you reported the theft to the police: YES NO (circle one)

Date reported to the police: Date:_____________________ Time:__________________ am/pm (circle one)

Name, address & phone # of the police department:___________________________________

__________________________________________________Report #_____________________

3. Despite diligent efforts exerted, I could not locate, find or recover the device and to the best of my knowledge, the

same is truly lost.

The said device has not been confiscated by any officer of the law or agency due to the violation of any law,

statute, order, rule or regulation.

In the event that the lost device should hereafter be found or located, I will undertake to forward or surrender the

same to Sedgwick – Attention claim #____________located at PO Box 94852; Cleveland OH 44101.

If any information provided in this affidavit is false, it may be the basis for a denial of your claim and possible legal

action (if applicable). This affidavit must be signed, notarized and returned to the claim administrator to complete

the loss reporting process. I understand that the insurance company may conduct reasonable inquiries into my

background, character, or credit history. Are the answers you have given true to the best of your belief? YES NO

Signature_____________________________________Witness:__________________________ (circle one)

Address______________________________________Address:__________________________

_____________________________________________ ___________________________