HomeMy WebLinkAbout4.29.16 Sworn Statement Proof of Loss POLICY NO.AH55368 SWORN PC6139
POLICY TERM: INS CLAIM NO.
11/01/13 to 11/01/14 STATEMENT IN
AMT OF BLDGS COV AT TIME PROOF OF LOSS Reynolds Insurance Agency Inc
OF LOSS: AGENT
$208,000.00 ANY PERSON WHO KNOWINGLY AND Port Arthur,TX
AMT OF CNTS COV AT TIME OFWITH INTENT
TO DEFRAUD ANY AGENCY AT
LOSS; INSURANCE COMPANY OR OTHER
$124,800.00 PERSON FILES A STATEMENT OF CLAIM
CONTAINING ANY MATERIALLY FALSE
INFORMATION,OR CONCEALS FOR
THE PURPOSE OF MISLEADING,
INFORMATION CONCERNING ANY FACT
MATERIAL THERTO,COMMITS A
FRAUDULENT INSURANCE ACT,WHICH
IS A CRIME.
TO Certain Underwriters at Lloyd's,London:
At the time of loss,by the above indicated policy of insurance,you insured the interest of Johnny&Sherri Bellard @ 401 5th Avenue,Port
Arthur,TX 77642 against loss to the property described according to the terms and conditions of said policy and of all forms,endorsements,
transfers and assignments attached thereto.
TIME AND ORIGIN A Loss to the Dwelling(Dwell).Personal Property(UPP)and Loss of Use(LOU)occurred about the hour of
12•o'clock P M.,on the 4 day of August 2014,the cause of the said loss was: Damage due to Water.
OCCUPANCY The premises described,or containing the property described,was occupied at the time of loss as follows,and
for no other purpose whatsoever: Insured
INTEREST No other person or persons had any interest therein or encumbrance thereon,except Johnny&Sherri Bellard
1. FULL AMOUNT OF INSURANCE(Dwell,UPP,&LOU)applicable for which claim is presented is. $ 374,400.00
2. ACTUAL CASH VALUE of building structures $ 0.00
3. ADD ACTUAL CASH VALUE OF CONTENTS or personal property insured $ 0.00
4. ACTUAL CASH VALUE OF ALL PROPERTY $ 0.00
5. FINAL COST OF REPAIR OR REPLACEMENT(Personal Property Only) $ 3,468.02
6. LESS REMAINING APPLICABLE DEPRECIATION(non recoverable) $ 591.59
7. ACTUAL CASH VALUE LOSS is $ 2,876.43
8. LESS DEDUCTIBLE and PRIOR PAYMENT $ 2,746.53
9. NET SUPPLEMENTAL AMOUNT CLAIMED under above numbered policy is $ 129.90
The said loss did not originate by any act,design or procurement on the part of your insured,nothing has been done by or with the
privity or consent of your insured to violate the conditions of the policy,or render it vpid;no articles are mentioned herein or in annexed
schedules but such as were destroyed or damaged at the time of said loss,no property saved has in any manner been concealed,and no
attempt to deceive the said insurer as to the extent of said loss,has in any mariner been made. Any other information that may be
required will be furnished and considered a part of this proof.
Subrogation–To the extent of the payment made or advanced under this policy;the insured herby assigns,transfers and sets over
to the insurer all rights,claims or interest that he has against any person,firm or corporation liable for the loss or damage to the property
for which payment is made or advanced. He also herby authorizes the insurer to sue any such third party in his name.
The insured herby warrants that no release has been given or will be given or settlement or compromise made or agreed upon with
any third party who maybe liable in damages to the insured with respect to the claim being made herein.
The furnishing of this blank or the preparation of proofs by a representative of e above' - .er is j' a w er of y of its ri .
State of 611/1444—)
Insured–Sia , -
County of 22
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