Renters Insurance Proof of Loss Statement
Policyholder Information
Name:
Address:
Policy Number:
Insurance Company:
Contact Number:
Loss Details
Date of Loss:
Location of Loss:
Cause of Loss:
Description of Loss/Incident:
Authorities Notified (if any):
List of Damaged or Lost Items
Description of Item
Date Purchased
Original Cost
Estimated Value
Comments
Additional Remarks
Signature:
Date: