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Amount of Policy <br />$ As per form <br />To <br />of <br />Issued Expires <br />Iv 1. 2017 iuIv 1. 2018 <br />LEXINGTON <br />SWORN STATEMENT Policy Number 0017471589 <br />In <br />Agency Name Alliant Insurance Services <br />FINAL PROOF OF LOSS <br />COMPANY <br />By the above indicated policy of insurance your insured PEPIP/DEC 2/City of Santa Ana <br />against loss by all risk of physical damage upon the property described, according to the terms and conditions of the said <br />Conditions of the said policy and all forms, endorsements, transfers and assignments attached thereto. <br />1. Time and Origin: A loss occurred about the hour of o'clock M., on the 7th day of September 20 18 <br />The cause and origin of said loss were: I Damage to Gym Floor <br />2. Occupancy: The building described, or containing the property described, was occupied at the time of the loss as follows, and for <br />no other purpose whatever: Jerome Center: 726 S. Center Street, Santa Ana, CA 92704 <br />3. Title and Interest When this policy was acquired and at the time of the loss the interest of your insured in the property described <br />therein was sole and unconditional ownership, and no other person or persons had any interest therein or incumbrance thereon. <br />(State exceptions, if any.) NO EXCEPTIONS <br />4. Changes: Since the said policy was acquired there has been no assignment thereof, or change of ownership, use, occupancy, <br />Possession, location or exposure of the property described, or of our insured's interest therein. (State exceptions, if any.) <br />5. Total Insurance: The total <br />6. The Cash Value of said property <br />7. The Whole Loss and Damage was <br />8. The Amount Claimed under the <br />The said loss did not original <br />done by or with the privity or consent <br />are mentioned herein or in annexed <br />possession of the said insured at the ti <br />the said company, as to the extent of <br />furnished and considered as part of th <br />The furnishing of this blank <br />any of their rights. <br />FOR YOUR PROTECTION, CALIF( <br />Any person who knowingly presen <br />fines and confinement in state priso <br />State of <br />County of <br />insurance upon the property described by this policy was, at the time of the loss, <br />time of loss was <br />Not Determined <br />$ 103,870.00 <br />e numbered policy ................................................................................... $ 95,870.00 <br />(Amount claimed is net applicable $10,000 deductible) <br />by any act, design or procurement on the part of your insured, or this affiant; nothing has been <br />f your insured or this affiant, to violate the conditions of the policy, or render it void; no articles <br />hedules but such as were in the building damaged or destroyed , and belonging to, and in <br />Le of said loss; no property saved has in any manner been concealed, and no attempt to deceive <br />aid loss, has in any manner been made. Any other information that may be required will be <br />the preparation of proofs by a representative of the above insurance company is not a waiver of <br />:NIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: <br />false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to <br />Subscribed and sworn to (or affirmed) before me on this day of <br />the person(s) who appear before <br />Claim No: 2957801035US <br />(Insured Signature) <br />Insured <br />(month), (year) by <br />proved to me on the basis of satisfactory evidence to be <br />(signature of Notary) <br />20B-7 <br />