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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 [START DATE] and expiring on [END 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 (not) specifically described in an attachment to the policy.

That, a [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:

[DESCRIPTION OF EVENTS "SEE ATTACHED REPORT"]

That, the property was legally and properly located at [LOCATION] 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 $[AMOUNT] ([SPELL OUT] dollars). The property was not covered by any other insurance policy.

That, the cash value of the property, at the time of [LOSS\DAMAGE] was $[AMOUNT] ([SPELL OUT] dollars). The replacement/repair cost of the property, at the time of loss, was $[NUMBER] ([SPELL OUT] dollars). That, loss and damage to the property totals $[NUMBER] ([SPELL OUT] dollars).

That, the amount claimed for the property totals [SUBTRACT DEDUCTIBLE AMOUNT FROM LOSS AND DAMAGE] $[NUMBER] ([SPELL OUT] dollars).

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.

NAME: