SOP_NUMBER: 404.03-att-2
TITLE: Sworn Proof of Loss Form
DIVISION: Administrative & Finance
TOPIC_AREA: 402-405 Policy-Administration and Finance
EFFECTIVE_DATE: 2020-07-01
WORD_COUNT: 349
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/173064
URL: https://gps.press/sop-data/404.03-att-2/

SUMMARY:
This is the official form used by the Georgia Department of Corrections to report and claim losses covered under the state's Property Insurance Program. The form requires detailed information about the loss, supporting documentation, and a sworn statement from the agency's Insurance Coordinator or highest-ranking official. Claims must be submitted within 120 days of the loss with required invoices, bills, and proof of payment to be reimbursed.

KEY_TOPICS: insurance claim, proof of loss, property damage, vehicle damage, building contents, risk management, DOAS claim, loss documentation, reimbursement, property insurance, damage claim, sworn statement, loss verification

ATTACHMENTS:
  1. Insurance Notice of Loss Form
     URL: https://gps.press/sop-data/404.03-att-1/
  2. Sworn Proof of Loss Form
     URL: https://gps.press/sop-data/404.03-att-2/
  3. Lightning Affidavit
     URL: https://gps.press/sop-data/404.03-att-3/
  4. Property Transfer Form
     URL: https://gps.press/sop-data/404.03-att-4/

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FULL TEXT:
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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.