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