Equipment Insurance
Proof of Loss

Policyholder Information

Name:

Address:

Phone Number:

Email:

Policy Number:

Loss Information

Date of Loss:

Location of Loss:

Description of Loss:

Equipment Details

Item Description:

Serial/ID Number:

Original Purchase Date:

Purchase Price:

Estimated Value at Time of Loss:

Additional Information

Police Report Number (if applicable):

Other Insurance (if any):

Remarks:

Signature Date