This is a statement by an insured party directed to an insurance company swearing to the nature and circumstances of a claimed loss.
Date policy issued: 12/10/2012
Date policy expires: Enter the date of expiration of the policy
SWORN STATEMENT IN PROOF OF LOSS
To the 12/10/2013.
At time of loss, by the above indicated policy of insurance you insured:
against loss by Premiumupon 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 outbreak loss occured about the hour of 9 :50Am, on 25TH February 2013. 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:
A room of about 10x14 ft in a first floor of a story building
Title and Interest: At the time of the loss the interest of your insured in the property described therein was as shown on the attached list.
Changes. Since the said policy was issued there has been no assignment thereof, or change of interest, use, occupancy, location or exposure of the property described.
Total insurance. The total amount of insurance upon the property described by this policy was, at the time of the loss, N2,428,880 (Two Million Four Hundred Twenty Eight Thousand,Eight hundred and Eighty Naira only) 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 N 3,139,241.00 (Three million , one hundred and thirty nine thousandtwo hundred).
The Whole Loss and Damage was N 3,139,241.00(Three million, one hundred and thirtynine thousand two hundred and forty one naira only)
The amount claimed under the above numbered policy is N 3,139,241.00 (Three million, one hundred and thirty nine thousand two hundred and forty one naira only
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 company is not a waiver of any of its rights.
State of Lagos state
County of Nigeria April, 2013