SWORN STATEMENT IN PROOF OF LOSS

AUTOMOBILE

TO: __________________________________

Regarding: Policy number: ____________

Policy period: _______________________

By the above mentioned policy of insurance, your insured _______

_________________, (hereinafter called the insured) against loss

or damage to the automobile described as follows:

Model Year: _________

Make: _______________

Type of body: _______

VIN: ________________

State/License number: ______ ______

A loss caused by collision occurred on _______________, about the

hour of _______ _m, as follows:

_________________________________________________________________

The insured was the sole owner of the automobile at the time of

the loss or damage and no other person had any interest therein,

by lease, bailment, mortgage, lien or other encumbrance or

otherwise except:

____________________________

At the time of this loss, there was no other insurance on said

automobile covering the same periods except:

______________________________________________________________

At the time of this loss, the automobile was used for:

_______________________________________________________________

and was not being used to carry passengers or for compensation or

rental or leased, or for any illegal or non-covered loss except:

_______________________________________________________________

The said loss or damage did not originate by any act, design or

procurement on my (our) part nor on the part of anyone having an

interest in the party insured, or in the said policy of

insurance; not in result or consequence of any fraud done or

suffered by me/us and that no property saved has been concealed.

It is expressly understood that the furnishing of this blank or

the preparation of this proof by a representative of the above

insurance company, ________________________, is not a waiver of

any of its rights.

_______________________________________________________

State of ________________________

County of _______________________

Sworn to and subscribed before me on ___________________________

________________________________.

_______________________________________________________

Notary Public