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Cream of the Crop 1
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Cream of the Crop 1.iso
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GUIDE61A.ARJ
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LHARC1.EXE
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3800.ARM
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1991-04-22
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94 lines
/* 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