Customer Statement of Loss

Provide your written statement about a loss incident. This form is typically requested as part of the claim process.

Customer Statement of Loss

Please provide your written statement about the loss incident. All fields marked with an asterisk are required.

Renter Information

First Name*

Last Name*

Email*

Phone*

Dealer Information

Dealer Name*

Dealer Contact First Name*

Dealer Contact Last Name*

Date of Loss*

Your Statement

Please describe what happened in your own words. Include details about how the incident occurred and any damage that resulted.

Example:

To whom it may concern, My name is John Doe. I rented a dozer from (Dealership's Name) to clear some land. While clearing the property on 5/5/2023, I was pushing over a tree when it caught onto another tree and fell on the cab of the dozer. The tree dented the cab of the dozer and shattered the front window. -John Doe

Your Statement*

Signature

Date Signed*

I certify that the information provided in this statement is true and accurate to the best of my knowledge. I agree to the privacy policy.*