Fill and Sign the Of the Appraisal Clause in Homeowners Policies Irmicom Form

Affidavit – Lightning Losses by Repairman or AppraiserClaims must be reported within 90 days . Name of Insured ________________________________________________ Address _______________________________________________________ Policy Number ___________________ Exp Date _____________________ 1. Date of Loss ____________________ Time of Loss ___________________ 2. Date reported for Repair _____________________________________________ 3. Fuses blown (if any) _________________ Amperages of Fuses ____________ 4. List of damages by bolt of lightning _____________________________________________________________________________________________________ 5. Description of damaged property Make __________________________ Model __________________________ Serial Number ____________________ 6. Age of equipment or parts damaged by lightning ___________________ 7. State reasons why loss appeared to be a result of lightning________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ STATE OF ____________________ COUNTY OF _______________________ PERSONALLY appeared before me, the undersigned authority in and for said county and state, ______________________ (Name of Affiant), who, having been being first duty sworn by the undersigned Notary Public, deposes and says: 1. The undersigned affiant examined the premises located at _______________________ __________________________________________ (street address, city, state, zip code), on _________________ (date). 2. It is the firm conviction of the undersigned that the loss described above was a direct result of lightning and was not occasioned by low voltage, mechanical or electrical breakdown, wear and tear or because of a defect. ________________________ (Printed Name of Affiant)________________________ (Signature of Affiant) SWORN to and subscribed before me, this the ____ day of _____________, 20____._____________________________ NOTARY PUBLIC My Commission Expires: ___________________