Fill and Sign the Sworn Statement Regarding Proof of Loss for Automobile Claim Form

Sworn Statement regarding Proof of Loss for Automobile Claim To: ________________________________(Name of insurance company)________________________________________________________________(Address of insurance company)Claim No. _______________ (number) I. Policy InformationA.Policy No. _______________ (number)B.Issue date _______________ (date) C. Expiration date ________________ (date)D. Agent ___________________ (name)E.Other insurer of vehicle __________________ (name)II. InsuredA.Name _______________________ (full name)B. Address ______________________________________________ __________________________ (address of insured)C. Home Phone No. _________________ D. Business Phone No. _________________ E. Social Security No. ________________________III. Insured VehicleA. 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. AccidentA.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 PropertyA. 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 PersonsNameAddressPhoneAge (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. WitnessesNameAddressPhone__________________(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. CertificationSTATE 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 PUBLICMy 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.