Affidavits
Sworn Proof of Loss for an Insurance Claim
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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.
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