#3800
@001 State the name of the insureds: 
@002 State the name of the insurance company:
@003 State the policy number:
@004 State the date that the policy commenced:
@005 State the date of expiration of the policy:
@400 State the model year of the car:
@401 State the make of the car:
@402/@402/@402/@402 State the type of body of the car:
Sedan
Truck
Van
KEY IN VALUE
@406 State the Vehicle ID number:
@404 Enter the state of registration and license number:
@405 State the reason for damage to car or loss:
@408 Please state the date of loss:
@409 Please enter the time of loss:
@410 Please state whether the loss was am or pm:
@411/@411/@411 Explain why loss occurred briefly:
Collision with other vehicle
Theft
KEY IN VALUE
@412 Please state any liens or encumbrances on vehicle:
@413/@413 State if other insurance on car or "none"
None
KEY IN VALUE
@414/@414/@414 State reason for use of the car at time of loss:
Pleasure
Business
KEY IN VALUE
@415/@415 State any non-covered reason for loss or "none"
None
KEY IN VALUE
#end control section
#3800
/* 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