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 |
(2)
b. The interest of all others in the damaged property (mortgagee, loss payee, assignee, etc.):
| NAME | INTEREST |
(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. |
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 |
(2)
b. The interest of all others in the damaged property (mortgagee, loss payee, assignee, etc.):
| NAME | INTEREST |
(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. |
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