do hereby declare that at or about

a loss occurred or occasioned, to the best of my /our knowledge and belief, in manner, following:

And I/We further declare that the property described overleaf, belonging to me/us and insured under the said policy, was lost and that the amounts severally stated represent the sum I/We am/are entitle to claim in terms of the policy.

I/We also declare that no other person has an interest in the said property, whether as owner, Mortgagee, Trustee, or otherwise and that it is not otherwise insured, except as under mentioned

I/We also declare that the whole statements made by me / us in this form of claim are in every respect true.