Fill and Sign the Sworn Statement 497331832 Form

Sworn Statement regarding Proof of Loss for Automobile Claim To: ________________________________ (Name of insurance company) ________________________________ ________________________________ (Address of insurance company) Claim No. _______________ (number) I. Policy Information A. Policy No. _______________ (number) B. Issue date _______________ (date) C. Expiration date ________________ (date) D. Agent ___________________ (name) E. Other insurer of vehicle __________________ (name) II. Insured A. Name _______________________ (full name) B. Address ______________________________________________ __________________________ (address of insured) C. Home Phone No. _________________ D. Business Phone No. _________________ E. Social Security No. ________________________ III. Insured Vehicle A. Make ___________________________ B. Type of body ___________________________________ C. Year model ___________ (model year of vehicle) D. Color ___________________ E. License Plate No. _______________, State _____ (name of state) F. Vehicle identification No. __________________________ G. Name of owner ________________________________ H. Address ______________________________________________ ___________________ (address of owner) I. Phone No. __________________ (phone number of owner) J. Driver at time of accident __________________ (name of driver)  Address ____________________________________________ _______________________ (address of driver)  Phone No. ________________ (phone number of driver)  Driver's License number ______________________ (number of driver's license)  Issued by State of _______________ (name of state)  Relation to insured party __________________ (relationship of owner to insured party)  Purpose of use of insured vehicle (description of purpose) ______________________________________  Authorized: Yes [ ] No [ ] K. Place where insured vehicle can be seen ____________________ _____________________________________________________ (description and address) IV. Accident A. Date of Accident ________________ (date) ; Time of Accident ___________ (time) B. Location of Accident _____________________________________ ___________________________ (street address, city, state, zip code) C. Description of accident or loss _____________________________ _____________________________________________________ _____________________________________________________ D. To whom reported __________________ (name of authority to whom incident reported) E. Date reported _______________ (date) ; Time reported _________ (time) V. Damage to Property A. Damage to insured vehicle ________________________________ _____________________________________________________ _________________________________ (description of damage) B. Estimated repair cost to insured vehicle $__________________ C. Damage to other vehicle _________________________________ _____________________________________________________ (description of damage) D. Estimated repair cost $ ___________ (dollar amount of estimated cost of repair to other vehicle) E. Description of other vehicle:  Make _________________________________  Type of body ___________________________  Year model _________ (model year of other vehicle)  Color ____________ (color of other vehicle)  License Plate No. ____________ (number of license plate of other vehicle)  State _____________ (name of state)  Vehicle identification no. _____________________ (identification number of other vehicle)  Place where other vehicle can be seen ______________________ _____________________________________________________ _________________________ (description and address) F. Insurance coverage of other vehicle: 1. Name of company _____________________________ (name of other vehicle's insurance company) 2. Policy No. _____________ (number of policy for other vehicle) 3. Period of coverage ________________________ (period of coverage for other vehicle) G. Name of owner of other vehicle _____________________ ______________________________________________ H. Address ______________________________________________ ____________________________ (address of owner of other vehicle) I. Phone No. _______________ (telephone number of other owner of vehicle) J. Driver of other vehicle ______________________ (name of driver of other vehicle) K. Address ______________________________________________ _________________________ (street address, city, state, zip code) L. Phone No. ______________________________________ M. Driver's License No. _________________________ N. Issued by State of _____________ (name of state) VI. Injured Persons Name Address Phone Age (in Years) Extent of Injuries _____________ (Name of injured person 1) ____________ ____________ (address of injured person 1) ______________ (phone number of injured person 1) _____ (age of injured person 1) ______________ ______________ ______________ (description of injuries 1) ______________ (Name of injured person 2) ______________ ______________ (address of injured person 2) _______________ (phone number of injured person 2) ______ (age of injured person 2) ______________ ______________ ______________ (description of injuries 2) ______________ (Name of injured person 3) ______________ ______________ (address of injured person 3) _______________ (phone number of injured person 3) ______ (age of injured person 3) ______________ ______________ ______________ (description of injuries 3) VII. Witnesses Name Address Phone __________________ (Name of witness 1) ________________________ ______________________ (address of witness 1) ________________ (phone number of witness 1) __________________ _______________________ _______________ (Name of witness 2) _______________________ (address of witness 2) (phone number of witness 2) __________________ (Name of witness 3) ________________________ ______________________ (address of witness 3) _____________ (phone number of witness 3) VIII. Remarks _______________________________________________ IX. Certification 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 foregoing statements are true and correct of my own knowledge. 2. No material fact has been withheld or concealed from insurer. __________________________ (Printed Name of Affiant) __________________________ (Signature of Affiant) SWORN to and subscribed before me, this the _____ day of ______________, 20_____. __________________________ NOTARY PUBLIC My Commission Expires: ___________________ NOTICE The furnishing of this form or the assistance given by a representative of this company in preparing this form is not a waiver of the company's rights or defenses.