SWORN STATEMENT IN PROOF OF LOSS
Amount of Policy at time of Loss: $__________
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POLICY NUMBER _________________________
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Policy Period __________________
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AGENT _________________________________
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AGENCY _____________________________________________
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To: _________________________________________
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At time of loss, by the above-indicated policy of insurance, your insured, __________________
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, against a loss by ___________
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to the
property described in the statement of loss, according to the terms and conditions of the said policy and all forms, endorsements, transfers
and assignments attached thereto.
1. Time and Origin: A __________
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occurred about the hour of ___________
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on the _____________________
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. The cause & origin
of the said loss were: ___________________________________________________________________________________
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2. 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: ______________________________________________________________________________________
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3. Title and Interest: At the time of the loss the interest of your insured in the property described therein was__________________
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.
No other person or persons had any interest therein or encumbrance thereon, except: ____________________________________
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4. Changes: Since the said policy was issued there has been no assignment thereof, or change of interest, use, occupancy, possession,
location or exposure of the property described except: ______________________________________________
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.
5. Total Insurance: The total amount of insurance upon the property described by this policy was, $_____________
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at the time of the
loss, as more particularly specified in the apportionment attached in the statement of loss, besides which there was no policy or
other contract of insurance written or oral, valid or invalid.
6. Actual Cash Value of said property at the time of the loss was $_____________________
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7. The Whole Loss and Damage was $_____________________
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8. The Amount Claimed under the above numbered policy is $_____________________
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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 insured hereby covenants that no release has been or will be given to or settlement or compromise made with any third party who may
be liable to damages to the insured and the insured in consideration of the payment made under this policy hereby subrogates the said
Company to all rights and causes of action the said insured has against any person, persons, or corporations whomsoever for damage arising
out of or incident to said loss or damage to said property and authorizes said Company to sue in the name of the Insured but at the cost of the
Company any such third party, pledging full cooperation in such action.
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.
"Any person who knowingly and with intent to defraud any insurance company, or other person, files an application for insurance or
statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact
material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties."
State of __________________________ County of ______________________________
The insured subscribed and sworn before me this day of ______________________________.
__________________________________________ ___________________________________________
Insured Insured
__________________________________________
Notary Public/or Adjuster
