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- #3800
- @001 State the name of the insureds:
- @002 State the name of the insurance company:
- @003 State the policy number:
- @004 State the date that the policy commenced:
- @005 State the date of expiration of the policy:
- @400 State the model year of the car:
- @401 State the make of the car:
- @402/@402/@402/@402 State the type of body of the car:
- Sedan
- Truck
- Van
- KEY IN VALUE
- @406 State the Vehicle ID number:
- @404 Enter the state of registration and license number:
- @405 State the reason for damage to car or loss:
- @408 Please state the date of loss:
- @409 Please enter the time of loss:
- @410 Please state whether the loss was am or pm:
- @411/@411/@411 Explain why loss occurred briefly:
- Collision with other vehicle
- Theft
- KEY IN VALUE
- @412 Please state any liens or encumbrances on vehicle:
- @413/@413 State if other insurance on car or "none"
- None
- KEY IN VALUE
- @414/@414/@414 State reason for use of the car at time of loss:
- Pleasure
- Business
- KEY IN VALUE
- @415/@415 State any non-covered reason for loss or "none"
- None
- KEY IN VALUE
- #end control section
- #3800
- /* Header on auto proof of loss */
-
- SWORN STATEMENT IN PROOF OF LOSS
- AUTOMOBILE
-
-
- TO: @002
-
- Regarding: Policy number: @003
-
- Policy period: @004 to @005
-
-
- By the above mentioned policy of insurance, your insured @001,
- (hereinafter called the insured) against loss or damage to the
- automobile described as follows:
-
-
- Model Year: @400
-
- Make: @401
-
- Type of body: @402
-
- VIN: @406
-
- State/License number: @404
-
-
- A loss caused by @405 occurred on @408,
-
- about the hour of @409 @410, as follows:
-
- @411
-
-
- 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:
-
- @412
-
-
- At the time of this loss, there was no other insurance on said
- automobile covering the same periods except:
-
- @413
-
-
- At the time of this loss, the automobile was used for:
-
- @414
-
-
- and was not being used to carry passengers or for compensation or
- rental or leased, or for any illegal or non-covered loss except:
-
- @415
-
-
- 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, @002, is not a waiver of any of its rights.
-
-
-
-
-
-
- _______________________________________________________
-
- @001
-
-
-
- State of ________________________
-
-
-
- County of _______________________
-
-
-
- Sworn to and subscribed before me on ___________________________
-
-
- ________________________________.
-
-
-
-
- _______________________________________________________
-
- Notary Public
-