PCA - RCC Proof of Loss Report

A sample of the "RCC Proof of Loss" report from proClaimer Appraisal. This, and all report formats used in proClaimer Appraisal are copyright © 1982-2007 by Mik Ro Software, All Rights Reserved.

YOUR COMPANY NAME                                                               Our No. 13579-01
YOUR MAILING ADDRESS                                                        Assigned: 10/01/2001
YOUR CITY, TX 12345-6789               RCC PROOF OF LOSS                   Contacted: 10/02/2001
123/456-7890                                                               Inspected: 10/02/2001
FAX-123/456-7890                                                         Report Date: 10/15/2001
                                                                                      Page No. 1

ATTN    : Claims Examiner                              Insured: Billy Sheffield
Company : Anyone's Fire & Casualty                              103 Ave Q
          P.O. Box 333159                                       Apt 7B
          Oklahoma City, TX 87531-                              Fort Worth, OK 76543-    
                                                      Phone # : 817/972-8463
                                                      Claimant: Billy Sheffield
Policy #: AFC-5-A-8712-545                                      103 Ave Q
Claim # : AFC-545-011002                              Location  Apt 7B
CAT. #  :                                              of Loss: Fort Worth, OK 76543-    

Agency  : Anyone's Local Agency                   Type of Loss: Water Damage
          Dallas, OK 75315-                       Date of Loss: 10/01/2001

Policy Coverages: HO-B, 101

Main Building: 1 Story, Composition Roof, Brick Veneer Construction.

          1.  FULL AMOUNT OF INSURANCE applicable to the property
              for which claim is presented was.............................     79,500.00

          2.  ESTIMATED FULL REPLACEMENT COST of the said property at the 
              time of the loss was ........................................     98,800.00

          3.  ESTIMATED COST OF REPAIR OR REPLACEMENT is ..................      2,015.80

          4.  Applicable DEPRECIATION is...................................        321.23

          5.  Estimated ACTUAL CASH VALUE LOSS is (Line 3 minus Line 4)....      1,694.57

          6.  Less DEDUCTIBLE(S) ..........................................        500.00

          7.  Estimated ACTUAL CASH VALUE CLAIM is (Line 5 minus Line 6)...      1,194.57

          8.  ESTIMATED SUPPLEMENTAL CLAIM, to be filed in accordance with 
              the terms and conditions of the Replacement Cost Coverage
              within 365 days from the date of loss as shown above,
              will not exceed (This figure will be that portion of the 
              amounts shown on Lines 4 and 6) which is recoverable.........        321.23



________/_______/________               ________________________________________ Insured
       Date Signed                                  Billy Sheffield             



State of ____________________

County of ___________________           

Subscribed and sworn to before me this ______day of ________________________ 19______

_________________________________________________________________Notary Public