POLICY NO.                                                                                                                     AMOUNT OF POLICY
____________________                                                                                $__________________________
AGENCY                                                                                                                    DATE OF INCEPTION
____________________                                                                                  _______/_______/___________
PROOF OF LOSS

INSURANCE COMPANY ____________________________________________________________________________________________________________________

By your Policy of Insurance above described, you insured
_________________________________________________________________________________________
TIME AND A ___________________________ occurred on the ________ day of _______________ 20___
ORIGIN and the hour of  ________ o'clock _______m.  The cause and origin of the said were ___________
LOSS       ___________________________________________________________________________
                 ___________________________________________________________________________
                 ___________________________________________________________________________
OCCUPANCY THE BUILDING (OR PREMISES) described, or containing the property described, was occupied at
                            the time of loss as follows: By____________________________________________________
                            as or for ___________________________________________________________________
                            __________________________________________ and for no other use.

OWNERSHIP     When your policy was acquired by the insured and at the time of said loss
AND CHANGES insured was the sole, absolute and unconditional owner of the property    described ad, if a building, of
                            the land on which it stood and no other    person or persons had any interest therein either as mortgagee
                            or otherwise; no incumbrance of said property existed nor has since been    made nor has there been
                            any change in the title, use, occupation, location    or possession of said property, except: __________
                            ___________________________________________________________________________

          (EXCEPTIONS, IF ANY, MUST BE STATED)
                            ___________________________________________________________________________
                            ___________________________________________________________________________
 
 

TOTAL                THE TOTAL INSURANCE including the above policy,  covering any
INSURANCE      or all such property at the time of loss, more particularly appearing in    schedule reciting all insurance,
                            whether valid or invalid, was . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .$ _____________

VALUE               THE CASH VALUE of said property at the time of the loss was  . . . . . . . . . . . .$_____________

LOSS                   THE LOSS AND DAMAGE was: . . . . . . . . . . . . . . . . . .. . . . . .. . . . .. .. . . .. .$ _____________

AMOUNT           THE AMOUNT CLAIMED under the above described policy CLAIMED  was . $_____________

STATEMENTS    The said loss did not originate by any act, design or procurement on the
OF INSURED      part of insured, or this affiant; nothing has been done by or with the    privity or consent of the insured,
                            or this affiant, to violate the conditions    of the policy or render it void; no articles are mentioned herein
                            or in annexed schedules but such as were in or on the premises described and    which belonged to and
                            were in possession of said insured at the time of    said loss.

                            No property saved has in any manner been concealed and no attempt to    deceive the  said Company
                            as to the extent or circumstances of said loss    has been made, and no material fact concerning said
                            loss withheld.  Any other information that may be required will be furnished on call and    considered a
                            part of this proof.  Claimant warrants freedom from any governmental restriction upon right    to receive
                            money here under because of citizenship or otherwise.
                           The furnishing of this blank or the preparation of proofs by a representative of the above
                            insurance company is not a waiver of any of its nights.

State of __________________                             ________________________________________________

County of _________________                            ________________________________________________
                                                                                                                          Insured.
Subscribed and sworn to before me this _____________ day of ___________________,20___.

                                                                                                          __________________________________(SEAL)
                                                                                                                                       (NOTARY Public)

FULLY COMPLETED PROOF OF LOSS WITH ITEMIZED REPAIR
BILLS OR ESTIMATES ATTACHED WILL SPEED UP PAYMENT.