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SUNZ Insurance Company - Loss History Affidavit 2026

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4.5 out of 5

51 votes

The document is a Loss History Affidavit from SUNZ Insurance Company, intended to validate a company's workers' compensation loss experience when official loss runs are unavailable. It requires completion by an owner or officer of the company, detailing any work-related injuries or claims within the past three years. The affidavit includes sections for company information, acknowledgment of loss history, and penalties for providing false information. Additionally, it requires acknowledgment from a PEO representative regarding the counseling on loss data presentation.

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Click ‘Get Form’ to open the SUNZ Insurance Company - Loss History Affidavit in our platform.
Begin by filling in the 'Company Information' section. Enter the name of the owner/officer and the legal name of the company. Ensure accuracy as this information is crucial for validation.
In the 'Loss History Acknowledgement' section, select one of the two options regarding work-related injuries. If applicable, provide details about any injuries experienced in the past three years, including employee names, injury dates, types of injuries, and total claim costs.
If there are more claims than can fit on the form, attach an additional sheet using the same format to ensure all information is captured.
Finally, sign and date the affidavit at the bottom. If a PEO representative is involved, they must also complete their section with acknowledgment.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (224 Votes)
2016	4.5 Satisfied (51 Votes)

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How do I write an affidavit for a lost document?

Sample Affidavit of Lost Document That I can no longer locate the original originally signed or produced ; That I made efforts to locate the document but all efforts to retrieve the said document have proved abortive; That I am in need of a certified true and correct copy of the document at this time.

What is Sunz insurance?

SUNZ Insurance is a national workers comp company headquartered in Bradenton, FL and develops unique workers compensation programs, delivering innovative and tailored solutions to protect businesses and their employees.

How to obtain an affidavit of loss?

You can have an Affidavit of Loss in the Philippines docHubd at a law office, notary public or, government official providing notarial service like PAO. The cost typically ranges from PHP 100 to PHP 500, depending on the notary public and location.

How to make an authorization letter for an affidavit of loss?

What sections should be included in a Authorization Letter For Affidavit Of Loss? Date and Place of Execution: Current date and location where the authorization letter is being executed. Principals Information: Complete name, address, and valid ID information of the person granting the authority.

Can I make an affidavit of loss on my own?

To make an Affidavit of Loss, draft or visit a notary public and write a sworn statement about the lost item and have it docHubd.

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