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 [STARTING DATE] and expiring on [END DATE] . That the policy insured [NAME(S) OF INSURED] against loss or damage to a [MODEL YEAR OF AUTO] , [MAKE OF CAR] , [BODY TYPE OF AUTO]. The automobile identification number was [VIN] . The automobile has [STATE] license plates bearing the following: [LICENSE PLATE].
That, a [LOSS/DAMAGE] caused by [REASON] was suffered by the insured on about [DATE] . The [LOSS/DAMAGE] occurred at about [TIME OF DAY] when [DESCRIPTION OF ACCIDENT]
That, the insured was (not) the sole owner of the auto at the time of [LOSS/DAMAGE] . [INDIVIDUALS OR PARTIES WITH AN INTEREST IN OR LIEN ON THE AUTO] were.
That, at the time of [LOSS/DAMAGE] there was no other insurance on this auto.
That, at the time of [LOSS/DAMAGE] the auto was being used for those 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.
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