1. On or about the ___________ day of _______________. 19________, defendant insured plaintiffs dwelling house (or other property, as the case may be) against loss or injury by fire and other perils in a policy of insurance, for the term of _____________ years.

2. The house (or other property) was wholly destroyed (or was damaged) by fire on the ___________ day of ____________________, 19_______, of which the defendant has had notice.

Wherefore plaintiff demands judgment against defendant in the sum of _______________ dollars, interest and costs.