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...