Sworn statement in proof of loss.
TO: State the name of the insurance company
Regarding: Policy number: State the policy number
Policy period: State the date that the policy commenced to State the date of expiration of the policy
By the above mentioned policy of insurance, your insured State the name of the insureds, (hereinafter called the insured) against loss or damage to the automobile described as follows:
Model Year: State the model year of the car
Make: State the make of the car
Type of body: State the type of body of the car
VIN: State the Vehicle ID number
State/License number: Enter the state of registration and license number
A loss caused by State the reason for damage to car or loss occurred on Please state the date of loss,
about the hour of Please enter the time of loss Please state whether the loss was am or pm, as follows:
Explain why loss occurred briefly
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:
Please state any liens or encumbrances on vehicle
At the time of this loss, there was no other insurance on said automobile covering the same periods except:
State if other insurance on car or "none"
At the time of this loss, the automobile was used for:
State reason for use of the car at time of loss
and was not being used to carry passengers or for compensation or rental or leased, or for any illegal or non-covered loss except:
State any non-covered reason for loss or "none"
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, State the name of the insurance company, is not a waiver of any of its rights.
State the name of the insureds
State of ________________________
County of _______________________
Sworn to and subscribed before me on ___________________________