#2980
@001 Enter the name of the insured:
@002 Enter the name of the insurance company:
@300 Enter the TOTAL policy amount (limits):
@301 Enter the date of issuance of the policy:
@302 Enter the date of expiration of the policy:
@303/@303/@303/@303 Enter type of insurance:
Personal property floater:
Homeowner's comprehensive:
Business personal property:
KEY IN VALUE:
@304/@034/@304/@304 Enter the reason for loss:
Fire
Theft
Vandalism
KEY IN VALUE
@305 Enter approximate time of loss:
@306/@306 The loss occurred:
A.M.
P.M.
@320 State the date of loss:
@307 Enter cause for the loss:
@308/@308/@308 Enter occupancy of structure:
Personal residence
Tenant dwelling
KEY IN VALUE
@309/@309/@309 The property claimed was:
Ownership
Long term lease
KEY IN VALUE
@310/@310 Enter any change in use or occupancy:
None
KEY IN VALUE
!311 Enter the policy limits of the coverage:
!321 Enter the total value of the damaged items:
!312 Enter the total amount of damages:
!313 Enter the amount claimed:
@314 Enter state where executed:
@315 Enter county where executed:
#end control section
#2980
/* Para 2980: Proof of loss, fire, theft */

Amount of policy: @300

Date policy issued: @301

Date policy expires: @302


                 SWORN STATEMENT IN PROOF OF LOSS


To the @002.

At time of loss, by the above indicated policy of insurance you
insured:

@001

against loss by @303, 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 @304 loss occured about the hour of @305
@306, on @320. The cause and origin of said loss were:

@307


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:

@308

Title and Interest: At the time of the loss the interest of your
insured in the property described therein was @309.

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:

@310

Total insurance. The total amount of insurance upon the property
described by this policy was, at the time of the loss, $ @311
(!311 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 $ @321 (!321 Dollars).

The Whole Loss and Damage was $ @312 (!312 Dollars)

The amount claimed under the above numbered policy is $ @313
(!313 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 @314

County of @315


Subscribed and sworn to before me this ______ day of __________

19______.





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