Sworn statement, T.H. Williams, Southern California, 1931 [image 1] |
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| Title | Sworn statement, T.H. Williams, Southern California, 1931 [image 1] |
| Description | Photograph of sworn statement, Southern California, 1931. "Form 1.A. No. 1, Policy Number U-2835, Agency at Los Angeles Calif, Amount of Policy $10,000.00, Commencement-Expiration 1/7/30-31, Sworn Statement in Proof of Loss to the Public Underwriters of the Public Fire Insurance Company of Newark N.J. By your Policy of Insurance above, you insured Arthur MacFarland, for account of whom it may concern (hereinafter called the Assured), according to the terms and conditions contained therein, the written portion thereof and all endorsements, transfers, and assignments thereon, being as follows: Per printed form covering $10,000 on Real and Personal Property situate Eureka Canyon, Stevens Ranch, four miles from Piru, Ventura County, California., Loss, if any, payable to Assured (copied of all endorsements, transfers, assignments and all the descriptions and schedules in all other policies will be furnished on demand.), A fire occured about the hour of 1:30 o'clock P.M. on the 12th day of February, A.D., 1930, by which the property described in said Policy was destroyed or damaged, as hereinafter more particularly set forth., The said fire originated as follows, viz,: unknown to this affiant, The total insurance (whether valid or not), covering said property or any part of the same, at the time of said fire; including the above policy, was the sum of $10,000.00, as more particularly set forth in schedules attached hereto and hereby made part hereof., The building described, or cotaining the property described, was occupied at the time of said fire, as follows, viz.: By Assured, xx, Except as noted below, the property described belonged at the time of fire to assured in fee simple (not held under lease), and no other person, or persons, had any interest, lien or incumbrance therein, or thereon, except none, Since the issue of said Policy there has been no assignment, or transfer, or incumbrance of said property, nor any change in the title, use, occupancy, location, possession or exposure of the same except none, The Cash Value of each specific subject thus situated and described by aforesaid policy at the time of the fire, and the Actual Loss and Damage to same caused by said fire, as shown by annexed schedule, and for which claim is hereby made, is as follows: Cash Value, Whole loss, Whole insurance, Amount Needed in this Policy, Amount Claimed under this Policy 8,883 69, item of policy, see schedule of loss attached, Total amount Claimed of this Company under above named Policy, $8,883.69, The said fire did not originate by any act, design or procurement on the part of assured, or this affiant; nothing has been done by or with the privity or consent of the assured or this affilant, to violate the conditions of this policy, or render it void; no articles are mentioned herein or in annexed schedules but such as were in the building damaged or destroyed, and belonging to, and in possession of the said assured at time of said fire; no property saved has been in any manner concealed, and no attempt to decieve the said company, as to the extent od said loss, has in any manner been made., Any other information that may be required will be furnished on call, and considered a part of these proofs. It is expressly understood and agreed, that the furnishing of this blank to the assured or the preparing of Proofs by an adjuster or any agent of the company named herein is not a waiver of any rights of said Company. Witness my hand at Los Angeles Calif., Arthur MacFarland. this 26th day of February 19230 For account of whom it may concern, assured, County of Los Angeles, State of California, ss. Personally appeared before me, the say and date above written Arthur MacFarland signer of the foregoing statement, who mafe solemn oath to the truth of same, and that no material fact is withheld of which the said Insurance Company should be dvised. Notary Public, (SEAL)" -- on paper. "Recieved, Loss Department" -- on stamp mark. "Canceled by loss no return premium" -- on stamp mark. |
| Subject (lcsh) | Legal documents |
| Filename | DW-1931-02-11-71~01.TIF |
| Archival file | Volume7/DW-1931-02-11-71~01.TIF |
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