1. On or about the ____ day of , defendant insured plaintiff’s 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 ______, of which the defendant has had notice.
Wherefore, (etc. as in Form 3).