CL37 (052021) Automobile Proof of Loss Page 1 of 1
Automobile Proof of Loss
Submit online at
or return to
Fax
icbc.com/claims
ICBC
PO BOX 2121, STN TERMINAL
VANCOUVER BC V6B 0L6
1-877-686-4222
CLAIM NUMBER CLAIMS REPRESENTATIVE PHONE NUMBER
To the Insurance Corporation of British Columbia (hereinafter called the “Corporation”):
I/we (hereinafter called the “Insured”) hereby claim
indemnity from the Corporation pursuant to the Insurance (Vehicle) Act and its Regulation (or the Insurance (MotorVehicle) Act and its
Regulation, depending on when coverage was purchased). This claim is for direct and accidental loss or damage to the following Insured
motor vehicle and/or its equipment:
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MOTOR VEHICLE
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TRAILER/SEMI-TRAILER
YEAR MAKE MODEL
BODY STYLE VEHICLE IDENTIFICATION NUMBER PLATE NUMBER DECLARED VALUE
During the term of the insurance, and at the time of the loss the vehicle was owned solely by the Insured and no other person or
corporation had any mortgage, lien or encumbrance thereon except as follows:
A loss occurred on , about the hour of am/pm and was caused by
The location was
The driver was
The particulars of other insurance relating to the above vehicle are
The actual loss or damage to the said vehicle and equipment was $
The total amount claimed under the terms of the insurance is $
The said loss or damage did not occur through the wilful act or procurement of the Insured and nothing has been done with the privity or
consent of the insured to violate the conditions of the insurance or render it void.
You are authorized to pay the above claim as follows:
$
$
$
Under payment of the total amount claimed and in consideration therefor the Corporation shall be discharged from all further claims by the
Insured by reason of the said loss or damage and all rights to recovery from any other person are hereby transferred to the Corporation
which is hereby authorized to bring action in the Insured’s name to enforce such rights.
The Insured agrees to indemnify the Corporation for any amounts of money which it may be required to pay by reason of any of the
statements herein being false.
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Statutory Declaration
to be completed
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Not required
WITNESS INSURED
DATE
STATUTORY DECLARATION
I, solemnly declare that the statements contained in the foregoing
Automobile Proof of Loss are true to the best of my knowledge, information and belief and I make this solemn declaration conscientiously
believing it to be true and knowing that it is of the same force and effect as if made under oath.
DECLARE before me at in the Province
of British Columbia,
this day of
A Notary Public in and for the Province of British Columbia
a Commissioner for taking Afdavits for British Columbia
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INSURED
