Affidavits
Sworn Proof of Loss for an Insurance Claim
Free template from Minute Notary, an Ontario notary office. A sworn proof of loss for a home, contents or vehicle insurance claim, for when your insurer asks for a statement under oath and has no proof-of-loss form of its own.
No charge until a notary signs it
Word files are editable. Review any changes carefully before signing or uploading.
Also known as
- Proof of loss
- Sworn statement in proof of loss
- Proof of loss affidavit
+2 more names
- Statutory declaration for an insurance claim
- Statement of loss for an insurance claim
The blanks fill themselves in as you type.
- Scope
- General template, not legal advice
- Formats
- PDF + editable Word downloads
- Builder
- Live preview as you type
Sworn Proof of Loss for an Insurance Claim
A compact preview of this template
01The insured and the policy
Your full legal name
Date of the loss
Items lost or damaged
SWORN STATEMENT IN PROOF OF LOSS
I, ______, of ______, in the Province of Ontario, MAKE OATH AND SAY:
I am the insured under policy number ______ issued by ______ (the “insurer”), and I have personal knowledge of the facts in this affidavit.
The loss happened on ______ at ______, which is where the property was at the time.
The cause of the loss was ______.
So far as I know or believe, the loss happened as follows: ______.
The property lost or damaged, when I acquired each item, and the value I claim for it, are as follows:
• ______ — acquired ______ — value claimed: ______
The total amount I claim for this loss is ______.
Payments I have already received for this loss, from the insurer or anyone else: ______.
The loss did not happen through any wilful act or neglect on my part, and I did not cause, arrange or consent to it.
No other insurance covers the property, except: ______.
Apart from me, the following persons have an interest in the property or a lien or charge on it: ______.
I make this affidavit to prove my loss under the policy. The list above is complete and accurate to the best of my knowledge.
Signed and sworn (or affirmed/declared) before me by videoconference in Ottawa, Ontario, while the Affiant(s)/Declarant(s) were located in ______________________, on ______________________, pursuant to O. Reg. 431/20, and Electronic Commerce Act, 2000.
______________________________ | ______________________________ |
- 01Work your wayGuided or All fieldsFinish one section at a time, or see every question in one form.
- 02See the resultLive document previewWatch this document update as you add each answer.
- 03Keep your placeSave and restore a draftSave progress in this browser, then restore it later on this device.
How it works
Prepare your document, one step at a time.
Answer the questions, choose the download you need, then continue with signing or booking.
Overview
About this document
- 01
What is a sworn proof of loss?
It is an affidavit in which the insured sets out the facts of a property, contents or vehicle loss and the amount claimed, and swears that the loss was not caused deliberately.
Insurers rely on it to settle the claim, so every line matters. Ontario's statutory conditions for fire insurance say a wilfully false statement in the declaration defeats the claim of the person who made it.
- 02
When you need one
Your insurer or adjuster may ask for a sworn proof of loss when:
- A fire, theft, water or collision claim needs the facts and the list of items under oath.
- The insurer will not pay, repair or replace until it receives a proof of loss.
- A contents claim needs an itemized list with dates and values.
- The insurer has no proof-of-loss form of its own, or accepts a statement in your own words.
- 03
What to include
Have these ready before you start:
- Your policy number, the insurer's name and any claim number.
- The date and place of the loss and what caused it.
- Every item lost or damaged, with when you got it and its value. Receipts, photos and bank records help you get the values right.
- Any payment you have already received, from the insurer or anyone else.
- Any other insurance on the same property, and anyone else with an interest in it, such as a mortgage lender or a car lease company.
- 04
Official source and who accepts it
Section 148 of Ontario's Insurance Act sets statutory conditions for fire insurance on property. They ask the insured to give the insurer written notice of the loss right away and to deliver, as soon as practicable, a proof of loss verified by statutory declaration. The insurer then pays within 60 days after the proof of loss is complete, unless the policy sets a shorter time.
For a vehicle, the statutory conditions for automobile insurance (O. Reg. 777/93) set a fixed limit: the sworn statement reaches the insurer within 90 days after the date of the loss or damage. For theft, water and other claims, your policy's own conditions apply. Your insurer decides whether it accepts this document; if it issues its own form, use that form.
- 05
Common mistakes
Avoid these:
- Using this template when the insurer has already sent its own proof-of-loss form.
- Guessing values or adding items you are unsure about. A wilfully false statement can cost you the whole claim.
- Leaving out other insurance, or a lender or leasing company with an interest in the property.
- Missing the deadline in your policy or in the statutory conditions.
- Signing before the appointment. You sign in front of the notary after the oath or affirmation.
- 06
How to get it notarized in Ontario
Fill in the form on this page and download a clean, ready-to-sign PDF. Do not sign it yet: an affidavit or statutory declaration is signed in front of a notary public or commissioner for taking affidavits, after the oath or affirmation.
When you are ready, book an appointment with Minute Notary. You can swear or affirm it before a notary by video from anywhere in Ontario, or in person on a mobile visit. Bring government-issued photo ID; the notary administers the oath or affirmation and applies the seal.
Good to know
Before you fill it in.
Short notes on this template. Worth a minute before you start.
- 01
Prepared for use in Ontario. A general template, not legal advice.
- 02
Notarize online by video across Ontario, or in person anywhere in Ontario.
- 03
Sign in front of the notary, who administers your oath or affirmation and applies the seal.
Official sources
Frequently asked
Questions about the Sworn Proof of Loss for an Insurance Claim
- Does my insurer have to accept this template?
- No. The insurer decides what proof it needs. If it sends its own proof-of-loss form, complete that form. This template is for when it asks for a sworn statement and leaves the wording to you.
- How long do I have to send a proof of loss?
- It depends on the policy. For fire insurance on property, Ontario's statutory conditions say as soon as practicable. For a vehicle, they set 90 days from the date of the loss or damage. Check your policy and any letter from your adjuster for the date that applies to you.
- Can I swear it by video?
- Yes. It is an affidavit, so a notary can commission it by video from anywhere in Ontario under Ontario's remote commissioning rules, or in person on a mobile visit.
- What should I bring to the appointment?
- Government-issued photo ID and the completed document, unsigned. Keep your receipts and photos for the insurer; the notary does not check values.
- Can someone else make the proof of loss for me?
- Ontario's fire insurance conditions let the insured's agent make the proof of loss when the insured is absent or unable to, if that is explained to the insurer. Ask your insurer first, and have the person who knows the facts swear it.
Keep exploring
Related templates
Other documents for banks, insurers, employers & pensions.
- 01Statutory Declaration in Support of an Insurance Claim
A sworn declaration setting out the facts of an insurance claim — used to support a claim for loss, theft, damage, or benefits. Fill it in online, download a ready-to-sign PDF, and notarize in Ontario.
Fill it out - 02Statutory Declaration of Employment and Income
A sworn declaration confirming your employment and income — used as proof of income for housing, credit, or a program that asks for a sworn statement when standard documents are unavailable. Fill it in online, download a ready-to-sign PDF, and notarize in Ontario.
Fill it out - 03Statutory Declaration of Loss of Earnings
A sworn declaration of income you lost — used to support an insurance, accident, or compensation claim. Fill it in online, download a ready-to-sign PDF, and notarize in Ontario.
Fill it out - 04Waiver of Independent Legal Advice
A waiver of independent legal advice records that a person chose not to obtain independent legal advice before signing a document, after being advised to do so. Consider the risks; obtaining advice is recommended.
Fill it out
Ready to sign?
Ready to create your Sworn Proof of Loss for an Insurance Claim?
Fill it in online, then download a ready-to-sign PDF or an editable Word copy. Use the generated PDF to continue to booking. Not sure what the appointment involves? Read about the Statutory Declarations service first.