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    Sworn Statement of Loss, Vehicle

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    FebriSatria
    The insured was the sole owner of the automobile at the time of the loss or damage and no other person had any interest therein, by lease, bailment, mortgage, lien or other encumbrance

    Copyright:

    © All Rights Reserved
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    Sworn Statement of Loss, Vehicle

    Uploaded by

    FebriSatria
    161 views3 pages
    The insured was the sole owner of the automobile at the time of the loss or damage and no other person had any interest therein, by lease, bailment, mortgage, lien or other encumbrance

    Copyright

    © © All Rights Reserved

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    RTF, PDF, TXT or read online from Scribd

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    The insured was the sole owner of the automobile at the time of the loss or damage and no other person had any interest therein, by lease, bailment, mortgage, lien or other encumbrance

    Copyright:

    © All Rights Reserved
    Download as RTF, PDF, TXT or read online from Scribd
    Download as rtf, pdf, or txt
    161 views3 pages

    Sworn Statement of Loss, Vehicle

    Uploaded by

    FebriSatria
    The insured was the sole owner of the automobile at the time of the loss or damage and no other person had any interest therein, by lease, bailment, mortgage, lien or other encumbrance

    Copyright:

    © All Rights Reserved
    Download as RTF, PDF, TXT or read online from Scribd
    Download as rtf, pdf, or txt
    of 3

    Sworn Statement of Loss, Vehicle

    TO: ____________________
    Regarding: __________________
    Policy number: __________________
    Policy period: _________________ to __________________

    By the above-mentioned policy of insurance, you insured __________________, (hereinafter


    called the insured) against loss or damage to the automobile described as follows:
    Model Year: __________________
    Make: ________________
    Type of body: _________________
    VIN: ___________________
    State/License number: _______________ _________

    A loss caused by __________________ occurred on ________________, about the hour of


    _________________ __________, as follows:
    __________________

    The insured was the sole owner of the automobile at the time of the loss or damage and no
    other person had any interest therein, by lease, bailment, mortgage, lien or other encumbrance
    or otherwise except:
    ___________________

    At the time of this loss, there was no other insurance on said automobile covering the same
    periods except:
    __________________

    At the time of this loss, the automobile was used for:


    ___________________

    and was not being used to carry passengers or for compensation or rental or leased, or for any
    illegal or non-covered loss except:
    __________________

    The said loss or damage did not originate by any act, design or procurement on my (our) part
    nor on the part of anyone having an interest in the party insured, or in the said policy of
    insurance; not in result or consequence of any fraud done or suffered by me/us and that no
    property saved has been concealed.
    It is expressly understood that the furnishing of this blank or the preparation of this proof by a
    representative of the above insurance company, ____________________, is not a waiver of
    any of its rights.

    _______________________________________________________
    __________________ By Owner

    State of ________________________
    County of _______________________

    Sworn to and subscribed before me on ___________________________________________.

    _______________________________________________________
    Notary Public
    My Commission Expires:
    Sworn Statement of Loss, Vehicle
    Review List

    This review list is provided to inform you about this document in question and assist you in its
    preparation. This statement is useful both for insurance claims and tax deductions for loss on
    your IRS and state forms.

    Use a notary. Large organizations like the niceties of this approach.

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