APPENDIX 4 PROPERTY PROOF OF LOSS

• Jurisdiction: United States

To: _____________________ An insurer

(hereinafter called the "Company").

Policy Number: _____________

Location of Property: _____________

You insure: ____________________________

(hereinafter called the "Insured").

A ________________________ loss occurred

on the _______ day of ___________, 20______

about the hour of _____o'clock ___m.,

and was caused by ___________________

[describe the cause of loss] ______________

Residence of insured at time of loss: _____________

Location of property at the time of loss:

__________________________

The policy insured the Insured against the risk of loss to:

Building(s) up to $___________________;

Personal Property/Contents $__________________;

Additional Living Expense $_________________;

Other coverage(s) described as: _______________

for $________________.

The values, at the time of loss of, were:

Building(s) $___________________.

Personal property/Contents $____________.

The normal living expenses of the Insured at the time of loss were:

$_________________________.

The value of the other property at the time of the loss was:

$___________________________.

The total insurance against the risk of loss to all of the property at the time of loss was:

$________________________.

All insurance with insurers other than the Company is listed on the schedule attached.

At the time of the loss the property, the risk of loss of which is insured, belonged[. . .]"

The building(s) described, or containing the property described, was occupied at the time of the loss for the following purpose:

_________________ and for no other purpose.

Since the policy was issued there has been no assignment thereof, or change of interest, use, occupancy, possession, location or exposure of the property except:
____________________________.

The loss incurred by the Insured(s) is:

Building: $___________________;

Personal Property/Contents: $________________;

Additional Living Expense: $_____________;

Other: $_______________;

The deductible amount...