Fill and Sign the Fire Claim Form

Proof of Loss for Fire Insurance Claim _____________________________________________________ (Name of Insurance Company) ________________________________________________________________________ (Mailing Address) Sworn Statement Regarding Proof of Loss Claim No. _________________________ I. Policy Data A. Policy no. ____________________ B. Date issued ___________________, Expiration date ___________________ C. Amount of policy $ ________________________ D. Agent ___________________________________ II. Insured A. Name ______________________________________ B. Social security no. ____________________________ C. Address _____________________________________ _____________________________________ _____________________________________ D. Residence phone ___________________, Business phone __________________ E. Address of property insured __________________________________________ _________________________________________ _________________________________________ F. Mortgagee ______________________________________________________ G. Address __________________________________________ __________________________________________ __________________________________________ H. Loss payee ________________________________________ I. Address ___________________________________________ ___________________________________________ ___________________________________________ III. Loss A. Date of loss _________________________________________ B. Time of loss _________________________________________ C. Cause or origin of loss [e.g., fire of undetermined origin started from a house at (address) which spread unchecked and reached the property insured which was burned completely] _____________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ . D. Description and amount of loss: Quantity Description of Property Cost Value at time of loss __________ _____________________________ _________ $_________________ __________ _____________________________ _________ $_________________ __________ _____________________________ _________ $_________________ E. To whom reported ________________________________________________ IV. Miscellaneous A. Purpose for which building insured or building containing property insured was used at time of loss ______________________________________________________ B. Persons occupying property insured at time of loss: _______________________ ________________________________________________________________________ ________________________________________________________________________ C. Interest of insured in property at time of loss (e.g., owner) ___________________ D . Other persons who had an interest in property at time of loss: ________________ ________________________________________________________________________ Name Nature of Interest __________________________________ ____________________________________ __________________________________ ____________________________________ E. Changes in use, occupancy, possession, location, or perils of property insured since issuance of policy: __________________________________________________ _______________________________________________________________________ F. Other insurance Name of Company Policy Number Amount ___________________________________ ____________________ $___________ The undersigned agrees that the furnishing of this form or the assistance in preparing this form given by any representative of the insurer is not a waiver of insurer's rights or defenses. Witness my signature, this the ___________________________________ (date) . ____________________________________ ________________________________ Name & Signature of Insured STATE OF ______________________________ COUNTY OF ____________________________ Personally appeared before me, the undersigned authority in and for the said County and State, on this _______________________________________ (date) , within my jurisdiction, the within-named ____________________________________________ (Name of Insured) , who, after being duly sworn by me, deposed and stated that the information set forth in the above Proof of Loss are true and correct as therein stated. SWORN to and subscribed before me this _______________________________ (date) . ______________________________ Notary Public My Commission Expires: _________________________