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Home > Self Insurance > Revenue Protection > Proof of Loss Form
Revenue Protection Program:
Sworn Statement in Proof of Loss Form

In the event of a covered Revenue Protection "occurrence:"

1. Notify California Fair Services Authority (CFSA).

2. Complete the "Sworn Statement in Proof of Loss Form" and have it notarized.

3. Document events (take pictures if applicable).

4. Obtain newspaper clippings or other written articles relating to loss.

5. Document extra (over and above normal) expenses paid to resume normal fairtime or covered interim event activities. Do not include hours normally worked.

What to include in a Revenue Protection claim:

1. Completed "Sworn Statement in Proof of Loss."

2. Because claims are generally paid based on the average of the previous three years of the following fairtime or covered interim event accounts, include revenue for this account for the current year ( don't include sponsorships):

  • Admissions (410)
  • Concessions (420)
  • Attractions (460)
  • Miscellaneous (470)
  • Other fairtime or covered interim event revenue generating accounts

3. Newspaper clippings or other articles verifying occurrence.

4. Accounting of extra expenses paid.

5. Send "Proof of Loss" statement and collateral to:         California Fair Services Authority
        Attn: Rick Wood
        P.O. Box 15518
        Sacramento, CA 95852-0518

If you have any questions about the Revenue Protection Program or about filing out this form, please contact Charlie Mitchell

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