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["SCHEDULE OF PROPERTY FORM"]
[]
["Instructions for use: ",null,null,"This template is for use by you, the insured, to record the contents items associated with your claim. "]
[null,null,null,"Once you have completed filling out the form, please sign and date it at the bottom and return to your adjuster."]
[null,null,null,"Please note, all items will be considered average condition unless otherwise indicated on the form. "]
["Key for Terms:"]
["Item #",null,null,"A reference number used to identify each item in the list."]
["Qty",null,null,"Enter the number of identical items that were lost or damaged."]
["Brand",null,null,"Enter the brand name or manufacturer name for the lost or damaged item  (ie..Sony, G.E, Maytag)."]
["Model #",null,null,"Enter the model number for the lost or damaged item if appliable."]
["Item Description",null,null,"Describe the physical appearance and the features for the lost or damaged item."]
["Condition",null,null,"Enter the condition of the lost or damaged item.  Should be (N) New, (L) Below Average, (M) Average, or "]
[null,null,null,"(H) Above Average."]
["Original Value Each",null,null,"Enter the amount you originally paid for the lost or damaged item."]
["Original Receipt  ",null,null,"Enter Y if the original receipt is attached or N if the original receipt is not attached."]
["Attached"]
["Item Age (years)",null,null,"Enter the actual or estimated age for the lost or damaged item using decimal amounts for partial years."]
["Item Age (months)",null,null,"Can be used with the Item Age (years) column to enter the number of years and months for the items age."]
["Place of Purchase",null,null,"Enter the vendor with whom the item was purchased."]
["Can Item be Repaired",null,null,null,"Enter Y if the item can be repaired or N if the item can not be repaired."]
["Insured's Repl. Cost Each",null,null,null,"If the item has already been replaced, enter the amount it cost to replace the item."]
[]
["Policyholder Name:  ",null,null,null,null,null,"Claim No:"]
["Loss Date:  (mm/dd/yyyy)",null,null,null,null,"Loss Location:  "]
["Police Dept. & Rpt. No:"]
["Details of Loss:"]
[]
["Loss State","(Click the down arrow to select the appropriate loss state and required compliance language)"]
["CA",{"$f":"VLOOKUP(A29,state_lang2,2,FALSE)","v":"For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison."}]
[]
["Item No.","Qty","Brand","Model #","Description \n(Include any relevant information that might affect the value of the property)","Condition\nN = New; \nL = Below Average; \nM = Average; H = Above Average","Original Value Each","Orginal Receipt Attached (Y/N)","Age Yrs.","Age Mos.","Place of Purchase","Can Item be Repaired (Y/N)","Insured's Repl. Cost Each"]
[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
[22]
[23]
[null,null,null,null,null,null,null,null,null,null,"Gross Total",null,{"$f":"+SUM(M32:M54)","v":0}]
[null,null,null,null,null,null,null,null,null,null,"Deductible"]
[null,null,null,null,null,null,null,null,null,null,"Total Other Pages"]
[null,null,null,null,null,null,null,null,null,null,"Net Total",null,{"$f":"(M55+M57)-M56","v":0}]
["The above given information, and any attachments, is true and correct.  I know of no other information of which the Company should be advised."]
[]
["Insured's Signature:",null,null,null,null,null,null,"Date: (mm/dd/yyyy)"]
["Title:"]

{"sheet":"Sheet2","index":1,"n_rows":53,"n_cols":2,"rows_kept":53,"cut":false,"hidden":false,"merged":[]}
["State","Put list in Alphabetical order by State"]
["AK","A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law."]
["AL","Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof."]
["AR","Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.  "]
["AZ","For your protection Arizona law requires the following statement to appear on this form.  Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties."]
["CA","For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison."]
["CO","It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages.  Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies."]
["CT"]
["DC","WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant."]
["DE","Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.   "]
["FL","Pursuant to s. 817.234, Florida Statutes, any person who, with the intent to injure, defraud, or deceive any insurer or insured, prepares, presents, or causes to be presented a proof of loss or estimate of cost or repair of damaged property in support of a claim under an insurance policy knowing that the proof of loss or estimate of claim or repairs contains any false, incomplete, or misleading information concerning any fact or thing material to the claim commits a felony of the third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084, Florida Statutes."]
["GA"]
["HI"]
["IA"]
["ID","Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.     "]
["IL"]
["IN","A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony."]
["KS"]
["KY","Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime."]
["LA","Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.   "]
["MA"]
["MD","Any person who knowingly OR willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison."]
["ME","It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company.  Penalties may include imprisonment, fines or a denial of insurance benefits.  "]
["MI"]
["MN","Any person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.   "]
["MO"]
["MS"]
["MT"]
["NC"]
["ND"]
["NE"]
["NH","Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud as provided in RSA 638:20."]
["NJ","Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties."]
["NM","Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.    "]
["NV"]
["NY","Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.   "]
["OH","Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.  "]
["OK","WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony."]
["OR"]
["PA","Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties."]
["RI","Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison."]
["SC"]
["SD"]
["State","      "]
["TN","It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company.  Penalties include imprisonment, fines and denial of insurance benefits."]
["TX","Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison."]
["UT"]
["VA","It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company.  Penalties include imprisonment, fines and denial of insurance benefits.   "]
["VT"]
["WA","It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company.  Penalties include imprisonment, fines and denial of insurance benefits.  "]
["WI"]
["WV","Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison."]
["WY"]

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