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:______________
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:__________________________
_____________________________________________ ___________________________
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Blank Affidavit of Loss Form PDF

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