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Sworn Statement To Insurer For Property Loss

KNOW ALL PERSONS BY THESE PRESENTS:

I, [Name], of [CITY, STATE], do hereby swear:

That, I maintained a policy, number [Policy Number], with [Insurer] during the policy period beginning on [Date] and expiring on [Date].

That, the policy insured [Name(s) of Insured] against loss of personal property according to terms and conditions of that policy.

High value items of personal property were never specifically described in an attachment to the policy.

That, [Loss & Damage] caused by [Reason for Loss] was suffered by the insured on about [Date]. The [Loss & Damage] occurred at about [Time of Day] when the following happened:

[See attached exhibit marked "A"]

That, the property was legally and properly located at [Address] when the [Loss & Damage] was suffered. The insured was the sole owner of all property at the time of the loss.

That, the total amount of insurance under the policy, for this property, was [$------]. The property was not covered by any other insurance policy.

That, the cash value of the property, at the time of [Loss & Damage] was [$------]. The replacement/repair cost of the property, at the time of loss, was [$------]. That, loss and damage to the property totals [$------].

That, the amount claimed for the property totals [Subtract Deductible from Loss & Damage] [$------].

That, at the time of [Loss & Damage] the property was being used and maintained for legal purposes permitted by the policy. The [Loss & Damage] was not the product of any act or plan on the insured's part or any other person's part with an interest in the insurance policy.

Signature

Name

Witnessed by:

This Section for Notary:

Acknowledgment

STATE OF -------)

) ss: [date]

COUNTY OF ------)

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.

[signature]

[Name of Notary Public]

My commission expires: [date]

(Seal)