Residential Property Endorsements HO-190, TX Homeowners Policy Sworn Statement In Proof of Loss, and TDP-014, TX Dwelling Policy Sworn Statement In Proof of Loss

Home Bulletins 1999 B-0042-99 August 16, 1999 To:   ALL PROPERTY AND CASUALTY COMPANIES Re:   Residential Property Endorsements HO-190, TX Homeowners Policy Sworn Statement In Proof of Loss, and TDP-014, TX Dwelling Policy Sworn Statement In Proof of Loss The Commissioner of Insurance, under Commissioner´s Order No. 99-1103, Docket No. 2411, has adopted amendments for residential property Endorsements, HO-190, Texas Homeowner Policy Sworn Statement In Proof Of Loss, and TDP-014, Texas Dwelling Policy Sworn Statement In Proof Of Loss. The above-prescribed forms utilized pre-printing of the century so that the year could be completed by supplying the last two digits. The endorsements are amended as follows: Delete: __________, 19__ Replace with: ____________, ____ (Month) (Year) The above endorsements are effective on October 1, 1999. Any questions regarding this bulletin should be directed to the Homeowners Section at 512-322-2266. Copies of the endorsements are attached to this bulletin. David P. Durden Deputy Commissioner Automobile and Homeowners Division DPD:GJ:lg ENDORSEMENT NO. HO-190 Effective October 1, 1999 TEXAS HOMEOWNER POLICY SWORN STATEMENT IN PROOF OF LOSS (This Form is Not a Release) POLICY NO: INSURING COMPANY NAME: NAMED INSURED (AS SHOWN ON THE ABOVE POLICY): The statements made in this sworn statement in proof of loss are to the best of my knowledge and belief. 1. Time and Cause of Loss: a. Date of Loss: b. Time of Loss: ____ a.m. ____ p.m. c. Cause of Loss: (explain) _________________________________________ ______________________________________________________________ ______________________________________________________________ 2. Interest: a. The interest of the insured's in the damaged property (owner, leasehold, etc.): INSURED'S NAME INTEREST (1) (2) b. The interest of all others in the damaged property (mortgagee, loss payee, assignee, etc.): NAME INTEREST (1) (2) 3. Other Insurance: If there is other insurance which may cover this loss, provide the company name(s) and policy number(s). COMPANY NAME POLICY NO. a. b. c. 4. Valuation of the damaged property at time of loss: PROPERTY DESCRIPTION ACTUAL CASH VALUE REPLACEMENT COST VALUE AMOUNT CLAIMED Dwelling $ $ $ Other Structures $ $ $ Personal Property $ $ $ Other $ $ $ _______________________ ____________ _______________________ ____________ Signature Date Signature Date Subscribed and sworn to before me this ___________ day of _____________, (Month) ______. (Year) Signed _______________________ My commission expires _________________ Notary Public in and for _______________________, Texas County Prescribed by the Texas Department of Insurance Endorsement No. HO-190 - Sworn Statement in Proof of Loss - Effective October 1, 1999 ENDORSEMENT NO. TDP-014 Effective October 1, 1999 TEXAS DWELLING POLICY SWORN STATEMENT IN PROOF OF LOSS (This Form is Not a Release) POLICY NO: INSURING COMPANY NAME: NAMED INSURED (AS SHOWN ON THE ABOVE POLICY): The statements made in this sworn statement in proof of loss are to the best of my knowledge and belief. 1. Time and Cause of Loss: a. Date of Loss: b. Time of Loss: ____ a.m. ____ p.m. c. Cause of Loss: (explain) _________________________________________ ______________________________________________________________ ______________________________________________________________ 2. Interest: a. The interest of the insured's in the damaged property (owner, leasehold, etc.): INSURED'S NAME INTEREST (1) (2) b. The interest of all others in the damaged property (mortgagee, loss payee, assignee, etc.): NAME INTEREST (1) (2) 3. Other Insurance: If there is other insurance which may cover this loss, provide the company name(s) and policy number(s). COMPANY NAME POLICY NO. a. b. c. 4. Valuation of the damaged property at time of loss: PROPERTY DESCRIPTION ACTUAL CASH VALUE REPLACEMENT COST VALUE AMOUNT CLAIMED Dwelling $ $ $ Other Structures $ $ $ Personal Property $ $ $ Other $ $ $ _______________________ ____________ _______________________ ____________ Signature Date Signature Date Subscribed and sworn to before me this ___________ day of _____________, (Month) ______. (Year) Signed _______________________ My commission expires _________________ Notary Public in and for _______________________, Texas County Prescribed by the Texas Department of Insurance Endorsement No. TDP-014 - Sworn Statement in Proof of Loss - Effective October 1, 1999 For more information, contact: ChiefClerk@tdi.texas.gov