..................Court,..................County,

................Term, 19........

State of...........

............County, ss.

...................................................plaintiff.., who, & the time the liability hereinafter mentioned accrued, were and ever since have been partners, under the firm name and style of.........................

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by....................................attorney.., complain of.........

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the defendant, which is a corporation, organized and existing under the laws of the State of....................and which has been duly summoned, of a plea of trespass on the case on promises:

For that, Whereas, to-wit: On the............day of..........

A. D. 19. .,at..............County aforesaid, the plaintiff........interested in and..............the owner.. of the property mentioned and described in the policy of insurance hereinafter set forth, which was of the value of

.............................................................Dollars, and so continued to be until the destruction of the same by fire, as hereinafter mentioned; and the said defendant.., on the same day, in consideration of a premium in money then and there paid to it therefor by the plaintiff.., made and delivered to the plaintiff.. a policy of insurance, of which the following is a true copy, and thereby undertook and promised as is therein set forth, to-wit:

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And the plaintiff.. aver.. that afterwards, and before the expiration of the time limited in said policy, to-wit, on the.......................day of..................A. D. 19...., the said property was accidentally, and by misfortune, totally consumed by fire, of which loss the said plaintiff.. forthwith gave notice to the defendant in writing, and as soon as possible thereafter, to-wit: on the same day, delivered to the defendant a particular account thereof under..........hand and verified by........oath, and did at the same time declare on oath what other insurance had been made on the same property, giving a copy of the written portion of each of said policies, and stating the whole value of the property insured, and the manner in which the building.. in which the loss occurred was occupied at the time of the loss, and who were the occupants, and how the fire originated, and did also at the time deliver to the defendant a certificate, under the hand and seal of a notary public most contiguous to the place of said fire, not concerned in 6aid loss nor related to the plaintiff.., that he, said notary, was acquainted with the character and circumstances of the plaintiff.., and verily believed that.........................really, and by misfortune, had sustained by said fire loss and damage to the amount of.........................dollars, and did duly perform all the acts and things required of................by said policy, and the defendant then and there received and accepted said proofs as satisfactory, and waived all objection thereto.

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Yet the said defendant, although often requested, and though more than sixty days have elapsed since the delivery of said proofs of loss, has not paid the said money or any part thereof to the plaintiff.., but to pay the same has neglected and refused, to the damage of the plaintiff.. of..............

.........................................................dollars, and, therefore,.............bring.. suit, etc.

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Attorney.. for Plaintiff..