NYC 9/11 Public Portal Document
24 ; 03:- : p3
1680-46u890-1
SWORN STATEMENT MJW#II
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PROOF OF LOSS A Et.T
n*IF iSSIJE
11/11101
Ac" C '
traveiere
of
ttittv Cqr. CQ tcia ?zo er
A144b►of ta"l inth p&kyofi i6KAf It f tf
tj ,h4.*
CiAT/g~ ■+ the prtaperty dow1bed under Schedule "A," occxxd'►ng to the
"a km by thar*M.
oarroltatsrsrmwsti. Martcfrstooid 0ytiyy~siaatt4ls-0reoc
tsrreu Qnd r r,drtwns of A m said paiicy and ail forma. .M,,
CAVIl Ioss occurred about the hour._ ___...jo'ckack
1. Tim and Origin: A . t .
an- ...-lj sop c hpr 2tL_JLL. The cause and Origin ot'the sold k►s. wee
property described, was Occupied at the time of the loss as follows.
2. 00ma oncy. The bwM.ktlnq .d,s rs wd. a< a Intoinrn the
and "for no atlter purpo:o wbotever: . !!_i ___--
ion the interest of yourunsvred In t1'. ptvutsty dk5.4*d th*teln was
3 Title end lnferest: Al the time of the
persoftew perror+s hod*AV :nler "tits r os iia .urtsbrsiatrap !Padres.
lie
ecptr
eugnment themof, a' ct!r?P,4rn ni 3ntew!ir urar, nrrrrrfx~n7..
4. Changes Since tlAa s+t► . vraa ived tlW ho?. been no t~ rxcelitisi
~crfbed.~roiltK:
p®esssaetiNart kn.otl? o*. * n~
this policy was. at ship Ikn*,saf the loss,
ct m.tiatgal arttour+t of ,nswonc up! ! the _pt p rli!descnl*d by.
ge tivarhitacfi ewd~nrS iiis C; beatncls* tii'ft thur er s
a
innact
eQ poUcTettiathsr col*oct of Unsurvna,Nt written or arse valid as
odwat ft k;m etas .... . . . .. ..... . . . ... .. • • , .#
6. The lhctaea4 Caaeti► V,4,14*of sea is"rn"#*f rat V
41.88
S9A
V
....
WOS ........ _ , •. .......... .. . ..... . . . . .. . ....... . ... .
y. The ~~ra~s A~ess etW
1 lass ofd. .............. ... .......................,...
is .......'- ..... .. ............ .
V .$ ~► ~ _ _.
The Atttotatt Claimed under tlwr uIJ13wr ravYtberred policy iktsattad'. or t ss affktntt inshisuit pus,
gA or p"~ CO.erne p nt
The svfd loss dfd' rwt' ovfgfrtorte bl! any' insured this Offir w4 b violet, the conditions of ucy or it void
been hs dori by or with the of consent of your or
such: as weac stiesporsed o4 damaged at the Sims of M toast
a*s.ir~*. *~ baa
iai"r t 4c t~s9r :rwr~ej! } prF orstesalet stdsse*vl! the sold QAt t~ etas eawtro a said fQ3s hats
praprsrty d h" kv" art of been ~ and c nsltfern-d a port of this proo..
will be furnished
40 AWY puma sr been mod.. Any other infarr>'tatnan that may irtrvtot+a i a fAcstsirrrrt++t Claim
ebiptrtF ps
Awl l -who towwv.~iwgiy-sswd w 4.iterst to purpose fiat wwarnfng any fact Maseru
consuming any matsdoity hale* Informat1on.wlgds or cnnascsls for she in ,
late,orb:" V .
theraass. sir i.otr'dt+la*t eM3eot0dr tsrsliltffve df tttiti PAtzzyllUa CaR arunptt W is ►acct is vvtatvcr
pruporotianc~fpr+oofs7#y 4
111 Form ev, f this fnntr nrthe. Scatlty t;a $mail 4 sc:Lasl p~roparty
Courtly of
.~~ wtd avtarA 1e beiors +Me *is_...
NYC-WTC 000099202
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