I/We, currently residing at the address mentioned, declare that I/we am/are: I/We hereby declare that the aforementioned statements constitute a complete, true, and accurate declaration. I/We further declare that the items listed on the reverse side were in my/our possession and ownership, and were insured under the above-mentioned insurance policy or policies. These items were destroyed or damaged due to the aforementioned accidental fire, without any intention or involvement on my/our part.

A detailed list of the items along with their respective values is attached herewith. Therefore, I/We claim from Pioneer Insurance Company Limited the sum of money equivalent to the amount of the said loss. I/We solemnly declare that I/We have not attempted to gain any undue benefit through fraud, deliberate misrepresentation, or concealment in connection with this fire incident. Believing this declaration to be true to the best of my/our conscience, I/We hereby submit this solemn statement. Let me know if you need this formatted as a document or need help with anything else.

I / We therefore claim the sum of Tk: