Sworn Statement in Proof of Loss
(Property Damage)

policy number: 3542646-345-D-34-X

Policy amt. at time of loss $890,000

date issued February 26, 2017

date expires March 26, 2017

Company claim number 8-46196-22617

Date Property Reviewed February 25, 2017

Agent Brian Williams

agency at Nationwide Insurance

To the Insurance company of Nationwide Insurance of Boston, Massachusetts. At the time of loss, by the above indicated policy of insurance you insured - Andrew Jackson Powers of the property at 24 UNION PARK, BOSTON, MASSACHUSETTS 02118 against loss by damage to the property described according to the terms and conditions of said policy and of all forms, endorsements, transfers, and assignments attached thereto.

time and origin
A flood loss occurred about the hour of 12:04 o'clock AM., on the 20th day of February, 2017. The cause and origin of the said loss were: burst pipes, freezing water.
The building described, or containing the property described, was occupied at the time of the loss as follows, and for no other purpose whatever: permanent residence.
title and changes
At the time of the loss, the interest of your insured in the property described there in was personal/residential interest. No other person or persons had any interest therein or encumbrance thereon. Since the said police was issued, there has been no assignment thereof, or change of interest, use, occupancy, possession, location, or exposure of the property described.
The total amount of insurance upon the property described by the policy was, at the time of the loss, $890,000, as more particularly specified in the apportionment attached, besides which there was no policy or contract of insurance, written or oral, valid or invalid.
The actual cash value of said property at the time of the loss was $1,200,000.
The whole loss and damage was $4,900,000.
AMT. Claimed
The amount claimed under the above numbered policy number is $890,000.
The said loss did not originate by any act, design, or procurement on the part of your insured, or this affiant; nothing has done by or with the privity or consent of your insured or this affiant, to violate the conditions of the policy, or render it void; no articles are mentioned herein or in annexed schedules but such as were destroyed or damaged at the time of said loss, no property saved has in any manner been concealed, and no attempt to deceive the said company, as to the extent of said loss, has in any manner been made. Any other information that may be required will be furnished and considered part of this proof.
Add. Information
The following is additional information from the Insurance Adjuster: The house is completely destroyed, water has damaged all three floors of the house. Pipe burst caused for flooding, and all furniture, electronics, clothing, and other material possessions have been completely destroyed. House is a complete loss, and the Insured is only looking for a pay out of policy that can be used towards rebuilding his life.

The furnishing of this blank or the preparation of proofs by a representative of the above insurance company is not a waiver of any of its rights.

State of Massachusetts, County of Suffolk, City of Boston.

Any person who knowingly and with intent to injure, defraud, or deceive any insurance company files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Signed By The Insured: Andrew Jackson Powers, 2/26/2017.
Signed By The Agent: Brian Williams, Notary, 2/26/2017.
Approved By Company: Nationwide Insurance, 2/26/2017.

Internal Company Notes: Property has been assessed and was part of the five house incident reported in the last week. Full payout of policy approved, property is a complete loss and will be marked as condemned until it is time to tear down the house and build new property in the same location. Insured has waived the right to build a new house on said property, and has signed to say he will not pursue the property once it is rebuilt. No foul play is suspected.