Flood Insurance Proof of Loss Statement
Policyholder Information
Policyholder Name
Policy Number
Contact Number
Property Address
Flood Event Details
Date of Loss
Time of Loss
Location of Loss
Description of Damage
Claimed Losses
Building Damage Amount
Contents Damage Amount
Total Claimed Amount
Supporting Details
List of Damaged Items
Additional Remarks
Certification
I certify that the above information is true and complete to the best of my knowledge.
Signature of Policyholder
Date