Date policy issued: ___________________
Date policy expires: __________________
To the ___________________________________. At time of loss, by the above indicated policy of insurance you insured:
_________________________________________________________ against loss by __________________________, upon the property described by the under Schedule “A,” according to the terms and conditions of the same policy and all forms, endorsements, transfers and assignments attached thereto.
Time and origin: A ____ loss occurred about the hour of _____, on the _______. The cause and origin of said loss were: _______________________________________________________________
Occupancy: The building described or containing the property described, was occupied at the time of the loss as follows, and for no other purpose whatever: _____________________________________________________________
Title and Interest: At the time of the loss the interest of your insured in the property described therein was _________.
Changes: Since the said policy was issued there has been no assignment thereof, or change of interest, use, occupancy, location or exposure of the property described, except: ______….
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