COMPANY CLAIM NUMBER
POLICY AMT. AT TIME OF LOSS
To the __[INSURANCE COMPANY NAME]_________________________________________________________________
of _____[CITY STATE]___________________________________________________________________________________
At time of loss, by the above indicated policy of insurance you insured-
against loss by ___________________________ to the property described according to the terms and conditions of said policy and of all forms,
endorsements, transfers and assignments attached thereto.
A ________________ loss occurred about the hour of _____o'clock AM/PM., on the ______ day of __________, 20__ .
The cause and origin of the said loss were: ____________________________________________________________________
The building described, or containing the property described, was occupied at the time of the loss as follows, and for no other
purpose whatever: ______________________________________________________________________________.
At the time of the loss, the interest of your insured in the property described therein was________________________ INTEREST
No other person or persons had any interest therein or
encumbrance thereon, except: ______________________________________________________________________________
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
THE TOTAL AMOUNT OF INSURANCE upon the property described by this policy was, at the
time of the loss,
$ ______________________________, as more particularly specified in the apportionment attached, besides which there was no
policy or other contract of insurance, written or oral, valid or invalid.
THE ACTUAL CASH VALUE of said property at the time of the loss was . . . . . . . . . . . . $ _____________________________
THE WHOLE LOSS AND DAMAGE was . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ ____________________________
THE AMOUNT CLAIMED under the above numbered policy number is………………... . $______________________________
The said loss did not originate by any act, design or procurement on the part of your insured, or this affiant; nothing has
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.
County Of _________________________
Subscribed and sworn to before me this _____________ day of ______________________________________________, ________
Personally Known to Me ________________
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURANCE COMPANY FILES A
STATEMENT OF CLAIM CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE