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Insurance Claim Form Building & Personal Property
(This form is based on the industry standard for a claim related to personal property or building damage.)
Date policy issued:
Date policy expires:
Sworn Statement In Proff of Loss
To the ____________ Insurance. At time of loss, by the above indicated policy of insurance you insured:
___________________name against loss by Homeowner's comprehensive:, 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 Fire loss occured about the hour of __:__ am/pm, on [Date].
The cause and origin of said loss were:
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:
Title and Interest: At the time of the loss the interest of your insured in the property described therein was Ownership. Changes. Since the said policy was issued there has been no assignmnet thereof, or change of interest, use, occupancy, location or exposure of the property described, except:
Total insurance. 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 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 $------. The Whole Loss and Damage was $------.
The amount claimed under the above numbered policy is $------ 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 comaony is not a waiver of any of its rights.
Subscribed and sworn to before me this ______ day of __________ 20 ___.
*** If Required By State Law ***
This Section for Notary:
State of _________
County of ________ [COUNTY]
On [DATE] before me, [NAME OF NOTARY], notary, personally appeared [NAME OF PERSON(S) INVOLVED], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
Witness my hand and official seal.
My commission expires: _____