Free Legal Forms
| Sworn Statement of Loss, Vehicle |
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TO: ____________________ Regarding: __________________ Policy number: __________________ Policy period: _________________ to __________________ By the above-mentioned policy of insurance, you insured __________________, (hereinafter called the insured) against loss or damage to the automobile described as follows: Model Year: __________________ Make: ________________ Type of body: _________________ VIN: ___________________ State/License number: _______________ _________ A loss caused by __________________ occurred on ________________, about the hour of _________________ __________, as follows: __________________ 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: ___________________ At the time of this loss, there was no other insurance on said automobile covering the same periods except: __________________ At the time of this loss, the automobile was used for: ___________________ and was not being used to carry passengers or for compensation or rental or leased, or for any illegal or non-covered loss except: __________________ 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, ____________________, is not a waiver of any of its rights. _______________________________________________________ __________________ By Owner State of ________________________ County of _______________________ Sworn to and subscribed before me on ___________________________________________. _______________________________________________________ Notary Public My Commission Expires: |
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