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...