DIY Legal Forms

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Sworn Statement To Insurer For Loss Of Vehicle


I, [Name] of [Address], do hereby swear that, I maintained a policy, number [Policy Number] , with [Insurer] during the policy period beginning on [Starting Date] and expiring on [End Date].

That the policy insured [Name(s) OF Insured] against loss or damage to a [Model, Make, Body Type and Year of Motor Vehicle]. The automobile identification number was [Motor Vehicle Vin Number]. The automobile has [State] license plates bearing the following:

[License Plate].

That, a [Loss / Damage] was caused by [Enumerate] was suffered by the insured on about [Date]. The [Loss / Damage] occurred at about [Time of Day] A.M./P.M., when [Describe the accident in detail].

That, the insured was (Not) the sole owner of the auto at the time of [Loss / Damage]. [Persons or Parties with an interest in or lien on the motor vehicleI] were [Name(s)].

That, at the time of [Loss / Damage] there was no other insurance on this auto.

That, at the time of [Loss / Damage] the auto was being used for those legal purposes permitted by the policy. The [Loss / Damage] was not the product of any act or plan on the insured's part or any other person's part with an interest in the insurance policy.



STATE OF -------)

) ss: [date]

COUNTY OF ------)

On [Date] before me, [Name of Notary], notary, personally appeared [Name of Person(s) Involved], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

Witness my hand and official seal.


[Name of Notary Public]

My commission expires: [date]