SOP 404.03-att-2: Sworn Proof of Loss Form

SOP 404.03
Attachment 2

7/1/20

State of Georgia Department of Administrative Services Risk Management Services

# SWORN PROOF OF LOSS

PROVIDE THE FOLLOWING INFORMATION BY FAX (478) 992-6363:
(IF FAX, RETAIN THE ORIGINAL DOCUMENT IN YOUR FILE)

DOAS CLAIM #: _________________________ AGENCY REFERENCE # ____________________

TYPE OF LOSS: (___) Building/Contents (__) All Risk (__) Vehicle Damage

If is a vehicle, Year______________ Make___________________ Model: _______________________

Date of loss: ______________ Time of loss: ________AM/PM Insured Agency __GDC______________

Loss Location: ________________ ______________________County_____________

Cause of Loss (Insured Peril): ___________________________________________________________

Loss Description (REQUIRED): _ ________________________________________ _________________

______________________________________________________________________________________

______________________________________________________________________________________
IF MORE SPACE IS NEDDED ATTACH A 2ND PAGE)

This form, copies of invoices for property, bills for material and labor, and evidence of payment (check or approved purchase
order) for replaced or repaired items must be provided to finalize a claim with in 120 days from Date of Loss. The required
documents substantiate reimbursement of damages for a claim. Processing of a claim in no way relieves an agency from
complying with purchasing or other regulations.

Please note that the Agency’s Insurance Coordinator or highest-ranking official must sign this form before reimbursement
will be made by DOAS. The undersigned swears that this reported loss did not originate by any known unethical or illegal act
on the part of the agency and nothing has been done to violate the policies of the state’s Property Insurance Program. The
only items included in this claim are items destroyed, stolen or damaged at the time of said loss; no property saved has in any
manner been concealed, disposed of or transferred to another location in an attempt to inflate the claim as to the extent of said
loss. If evidence is discovered of such deceit, it will render the contract of insurance void. Any information and documents
that may be required will be furnished or made available upon request and considered a part of this Proof of Loss.

CLAIM AMOUNT: ____________ Notary: State of Georgia, County of _______________.

DEDUCTIBLE ( ): ____________ This _______ day of ____________ subscribed before

REIMBURSEMENT: ____________ me this Date and year set out.

_____________________________________ _____________________
Insurance Coordinator or Highest Ranking Official Title

______________________________ __________________________
Phone Number Fax Number

Retention Schedule: Upon completion, this form shall be retained for five (5) years and then be
destroyed.