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Complete Home & Office Legal Guide
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Complete Home and Office Legal Guide (Chestnut) (1993).ISO
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2980.fib
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1993-08-01
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65 lines
Date policy issued: ___________________
Date policy expires: __________________
SWORN STATEMENT IN PROOF OF LOSS
To the ___________________________________.
At time of loss, by the above indicated policy of insurance you
insured:
_____________________________________________________________
against loss by __________________________, upon the property
described by the under Schedule "A," according to the terms and
conditions of the same policy and all forms, endorsements,
transfers and assignments attached thereto.
Time and origin: A ____ loss occured about the hour of ____ __m.,
on the _______. The cause and origin of said loss were:
_______________________________________________________________
Occupancy: The building described or containing the property
described, was occupied at the time of the loss as follows, and
for no other purpose whatever:
_____________________________________________________________
Title and Interest: At the time of the loss the interest of your
insured in the property described therein was _________.
Changes. Since the said policy was issued there has been no
assignment thereof, or change of interest, use, occupancy,
location or exposure of the property described, except: ______.
Total insurance. The total amount of insurance upon the property
described by this policy was, at the time of the loss, $
____________ ( ____________&___/100 Dollars) as more particularly
specified in the apportionment attached under Schedule "C,"
besides which there was no policy or other contact of insurance,
written or oral, valid or invalid.
The actual cash value of said property at the time of the loss
was $ ____________ ( ____________&___/100 Dollars).
The Whole Loss and Damage was $ ____________ ( ___________ &
___/100 Dollars)
The amount claimed under the above numbered policy is $
______________ ( ____________&___/100 Dollars)
The said loss did not originate by any act, design or procurement
on the part of your insured, or this affiant; nothing has been
done by or with the privity or consent of your insured or this
affiant, to violate the conditions of the policy, or render it
void; no articles are mentioned herein or in annexed schedules but
such as were destroyed or damaged at the time of said loss; no
property saved has in any manner been concealed, and no attempt to
deceive the said company as to the extent of said loss, has in any
manner been made. Any other information that may be required will
be furnished and considered a part of this proof.
The furnishing of this blank or the preparation of proofs by a
representative of the above insurance company is not a waiver of
any of its rights.
State of ___________
County of __________
Subscribed and sworn to before me this ______ day of __________
19______.
_____________________________________________