CLAIM ID: 2304SK039

SCHEDULE OF LOSS CLAIM DATE: Apr 1, 2023

REPORT DATE: Apr 28, 2023
INSURED: Osman Ahmed Syed

AGE REPLACEMENT DEPRECIATION ACTUAL CASH REPLACEMENT BALANCE OF

NO. DESCRIPTION BRAND MODEL QTY PURCHASE PRICE COST VALUE VALUE INVOICE AMT. CLAIM
Y M % AMOUNT

Unit 5
Assorted Lace, Elastic Band 5pc
201 1 $0.00
Electric Shavers And Cord 3pc
202 1 $0.00

203 Bike Accessories 2 Pc 1 $0.00

Assorted Cords, Head Phone Rubber Attachments 11pc
204 1 $0.00

Assorted Medication, Kleenex, Ziploc Baggies 4 Pc

205 1 $0.00

206 Assorted Paper Art 1 $0.00

Assorted Paper Products 7pc
207 1 $0.00

208 Misc Items 11pc 1 $0.00

209 Assorted Clips 7pc 1 $0.00
Assorted Ribbons, And Lanyards 7pc
210 1 $0.00
Assorted Bracelets 6pc
211 1 $0.00
4- Tennis Balls, 1- Key Chain
212 1 $0.00
Assorted Art Supplies 7pc
213 1 $0.00

Storage Room
4-wheels Large Luggage Bag, Maroon, Secure Brand
33 1 $0.00

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 CLAIM ID: 2304SK039
SCHEDULE OF LOSS CLAIM DATE: Apr 1, 2023
REPORT DATE: Apr 28, 2023
INSURED: Osman Ahmed Syed

AGE REPLACEMENT DEPRECIATION ACTUAL CASH REPLACEMENT BALANCE OF

NO. DESCRIPTION BRAND MODEL QTY PURCHASE PRICE COST VALUE VALUE INVOICE AMT. CLAIM
Y M % AMOUNT
2-wheels Large Luggage Bag, Beelite Brand
37 1 $0.00

2-wheels Carry-on Luggage, VIP Brand

39 1 $0.00
4-wheel Large Luggage, Wagon R Brand
41 1 $0.00

Noma Bagless Canister Vacuum

45 1 $0.00
Empty Box Of Chair, JYSK
54 2 $0.00
20lbs Whole Wheat Flour
55 1 $0.00
10lbs Gold Bismati Rice
56 1 $0.00

57 Conair Hair Dryer 1 $0.00

Black+Decker Steam Iron
58 1 $0.00

59 200mL Kirkland Juice 24 $0.00

Marveo Avengers Puzzle; Tumbling Tower, 48 Pcs
60 1 $0.00

Boxes Of 3-ply Kleenex

61 11 $0.00

62 Dove Bar Soap 20 $0.00

170mL Colgate; 4- pcs Oral B Toothbrushes
63 1 $0.00
Box Of Quality Street Caramels
65 1 $0.00

66 Vacuum Seal Bags 14 $0.00

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 CLAIM ID: 2304SK039
SCHEDULE OF LOSS CLAIM DATE: Apr 1, 2023
REPORT DATE: Apr 28, 2023
INSURED: Osman Ahmed Syed

AGE REPLACEMENT DEPRECIATION ACTUAL CASH REPLACEMENT BALANCE OF

NO. DESCRIPTION BRAND MODEL QTY PURCHASE PRICE COST VALUE VALUE INVOICE AMT. CLAIM
Y M % AMOUNT
Plastic Bags For Bedsheet (1) And Pillowcases (6)
68 1 $0.00

Assorted Candies/Chocolates
77 1 $0.00
Hand And Foot Warmers
81 1 $0.00
2- 375g Vaseline Jelly; 1- 1.18L Dove Shampoo; 1- 600mL Vaseline Lotion; 3- 591mL Body Wash

84 1 $0.00

88 Hair Colors 1 $0.00

Recyclable 4L Jugs, Bottles, and Styrofoams
92 1 $0.00

95 Empty Boxes 1 $0.00

97 Men's Belt 1 $0.00
98 Brooms 2 $0.00
100 Baseball Bat 1 $0.00
236mL Wood Glue, 150mL White Glue, Twist Green Apple
102 3 $0.00

Philips Shaver Accessories

106 1 $0.00

113 Paper Towel 1 $0.00

2- Boxes Of 4 Vitakin D3, 5- Sachets Emergen-C, 5- Sachets Cinnamon Orange Tea

117 1 $0.00

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 CLAIM ID: 2304SK039
SCHEDULE OF LOSS CLAIM DATE: Apr 1, 2023
REPORT DATE: Apr 28, 2023
INSURED: Osman Ahmed Syed

AGE REPLACEMENT DEPRECIATION ACTUAL CASH REPLACEMENT BALANCE OF

NO. DESCRIPTION BRAND MODEL QTY PURCHASE PRICE COST VALUE VALUE INVOICE AMT. CLAIM
Y M % AMOUNT
3- XLarge Plastic Bags, 5- Shopping Bags
123 8 $0.00

127 Beach Ball 1 $0.00

128 Spray Mop 1 $0.00
4- pcs AAA Panasonic Battery, 5- Rolls Thread
131 1 $0.00

Armani Eyeglasses Case; Mirror

133 1 $0.00

134 Water Flossers 1 $0.00

135 50mL Mont Blanc Ink 1 $0.00
144 Broom And Dustpan 1 $0.00
145 16x24in Door Mat 2 $0.00
146 Assorted paper clips 20 $0.00
147 Keychains 2 $0.00
Assorted Screws, door hinges
149 1 $0.00

150 Empty Boxes 1 $0.00

Bathroom
183 Shower curtain 1 $0.00
185 Toilet Brush 1 $0.00
Plastic Bucket, Empty Bottle
186 1 $0.00

Bedroom 1
Over The Door Steelcraft Hook Rack
13 1 $0.00
Sealy Queen size Mattress
17 1 $0.00

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 CLAIM ID: 2304SK039
SCHEDULE OF LOSS CLAIM DATE: Apr 1, 2023
REPORT DATE: Apr 28, 2023
INSURED: Osman Ahmed Syed

AGE REPLACEMENT DEPRECIATION ACTUAL CASH REPLACEMENT BALANCE OF

NO. DESCRIPTION BRAND MODEL QTY PURCHASE PRICE COST VALUE VALUE INVOICE AMT. CLAIM
Y M % AMOUNT
Ottoman with storage 14"x14"x14"
18 1 $0.00

19 Queen Size Pillows 2 $0.00

20 Tablecloth 50”x68” 1 $0.00
Large Giordano and Polo Royal Luggages
26 2 $0.00
Assorted medicine Products
31 1 $0.00
Plastic Basket 13”x2.5”x5”
32 1 $0.00
3-envelopes, 1-pencil, 1-stylus, 1-stationery clip
34 1 $0.00

1-napkins, 1-paper handkerchiefs, 1-washcloth, 2-condoms, 1-feminine sanitary pads

40 1 $0.00

1-Flick Basketball,1- Empty Box 1- 1- Paint Brush, 1- Gift Bag, 3- Gift Tags

42 1 $0.00

Nestle Dark Mint Thins 300g

43 1 $0.00

44 Empty Boxes 2 $0.00

Bedroom 2
2 Sets Of Twin Size Mattress And Bedframes
1 2 $0.00

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 CLAIM ID: 2304SK039
SCHEDULE OF LOSS CLAIM DATE: Apr 1, 2023
REPORT DATE: Apr 28, 2023
INSURED: Osman Ahmed Syed

AGE REPLACEMENT DEPRECIATION ACTUAL CASH REPLACEMENT BALANCE OF

NO. DESCRIPTION BRAND MODEL QTY PURCHASE PRICE COST VALUE VALUE INVOICE AMT. CLAIM
Y M % AMOUNT
Queen Size Memo Pillows
2 2 $0.00

3 Body Pillow 1 $0.00

Twin Size Mattress Protectors
4 2 $0.00

5 Stuffed Toys 2 $0.00

6x4 Outdoor Woven Rug/Mat
8 1 $0.00

12 Plastic Hangers 32 $0.00

Assorted Toys And School Supplies
21 1 $0.00

24 Kids' Belts 2 $0.00

25 Belt For A Kid's Dress 1 $0.00

Kitchen
Kitchen Table 71"×35.5"×29.5"
6 1 $0.00
Kitchen Chairs 17"×18"×38"
7 4 $0.00
Plastic Table Cloth 75"×55"
14 1 $0.00
Panasonic Inverter Microwave TYPE S333
15 1 $0.00
Cutting Boards And Pot Holders
22 1 $0.00

23 Dish Rack 1 $0.00

27 Toastmaster Toaster Toastmaster TM-26TSC 1 $0.00
28 Bag Water Bottles 2 $0.00
29 Cup Storage Rack 1 $0.00

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 CLAIM ID: 2304SK039
SCHEDULE OF LOSS CLAIM DATE: Apr 1, 2023
REPORT DATE: Apr 28, 2023
INSURED: Osman Ahmed Syed

AGE REPLACEMENT DEPRECIATION ACTUAL CASH REPLACEMENT BALANCE OF

NO. DESCRIPTION BRAND MODEL QTY PURCHASE PRICE COST VALUE VALUE INVOICE AMT. CLAIM
Y M % AMOUNT
Cutlery Organizer Plastic Baskets, Microwave Cover & Paper Towel Holder

30 1 $0.00

35 1/4 Dates 1 $0.00

38 Assorted Condiments 1 $0.00
46 Nuts 1 $0.00
Coffee And Assorted Spices
47 1 $0.00
Assorted Cooking Igredients
48 1 $0.00
Assorted Cooking Ingredients
49 1 $0.00

50 Spice Mixes 7 $0.00

51 800g Cream Of Wheat 3 $0.00
52 Cooking Ingredients 1 $0.00
Unknown Spices/Cooking Ingredients
53 1 $0.00

Assorted Cookies And Bars

64 1 $0.00

73 Assorted Pastas 1 $0.00

86 Assorted Bags Of Rice 1 $0.00
Vegetable Flavor Noodles
124 10 $0.00

125 Popcorn 1 $0.00

130 Spice Mixes 4 $0.00
137 Papad 3 $0.00
148 Chow Mein Noodles 3 $0.00
Betty Crocker Foil Containers And Lids
151 2 $0.00

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 CLAIM ID: 2304SK039
SCHEDULE OF LOSS CLAIM DATE: Apr 1, 2023
REPORT DATE: Apr 28, 2023
INSURED: Osman Ahmed Syed

AGE REPLACEMENT DEPRECIATION ACTUAL CASH REPLACEMENT BALANCE OF

NO. DESCRIPTION BRAND MODEL QTY PURCHASE PRICE COST VALUE VALUE INVOICE AMT. CLAIM
Y M % AMOUNT
Kirkland Almonds 1.36kg
152 1 $0.00
Kirkland Signature Mayonnaise (Empty)
153 1 $0.00
3- 100' Alcan; 1- 164ft Cling Wrap
154 1 $0.00

155 Granola 1 $0.00

1- Paper Towel, 1- Wipes
156 1 $0.00

157 Chia seeds In A Jar 1 $0.00

1L Gallo Virgin Coconut Oil
158 1 $0.00
1.25kg Nestle Mini Bars
159 1 $0.00

160 Foam Cups 1 $0.00

161 Сardamom seeds 1 $0.00
500g Horlicks, 500g Dabur Chyawanprakash, 66g Hajmola

162 1 $0.00

Roasted Chickpea In Plastic Container

163 1 $0.00
5mL Vitamin D, 5mL Ddrops
164 2 $0.00
French’s Mustard 830g, Apple Cider Vinegar 500mL, Kraft BBQ Sauce 455mL

165 1 $0.00

999 Kesar Yellow & Orange Red

166 1 $0.00

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 CLAIM ID: 2304SK039
SCHEDULE OF LOSS CLAIM DATE: Apr 1, 2023
REPORT DATE: Apr 28, 2023
INSURED: Osman Ahmed Syed

AGE REPLACEMENT DEPRECIATION ACTUAL CASH REPLACEMENT BALANCE OF

NO. DESCRIPTION BRAND MODEL QTY PURCHASE PRICE COST VALUE VALUE INVOICE AMT. CLAIM
Y M % AMOUNT
Haldiram’s Boondi Indian Snacks 350g, Great Value Ice Cream Cups 79g, Pot Of Gold Dark Chocolate Collection 248g

167 1 $0.00

168 200g Imli Candy 1 $0.00

169 Cleaning Supplies 3 $0.00
170 Hot kitchen stand 1 $0.00
PRESSURE COOKER part
171 1 $0.00

172 Chicken Broth 1 $0.00

Parachute coconut oil 500mL
173 1 $0.00

174 Water filter pitcher 1 $0.00

Spoons And Stainless Steel Scrub
175 1 $0.00

176 Bag Of pulse candy 1 $0.00

177 10mL Cooking Oil 1 $0.00
Brush With Long Handle
178 1 $0.00
Hershey’s Cocoa 100% Cacao 226g
179 1 $0.00
Tim Hortons Hot Chocolate 1.5 Kg
180 1 $0.00
10kg & 1.81kg Flour; 2.58kg Quaker Oats
181 3 $0.00

182 3.6kg Popcorn 1 $0.00

184 Assorted Spices 1 $0.00

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 CLAIM ID: 2304SK039
SCHEDULE OF LOSS CLAIM DATE: Apr 1, 2023
REPORT DATE: Apr 28, 2023
INSURED: Osman Ahmed Syed

AGE REPLACEMENT DEPRECIATION ACTUAL CASH REPLACEMENT BALANCE OF

NO. DESCRIPTION BRAND MODEL QTY PURCHASE PRICE COST VALUE VALUE INVOICE AMT. CLAIM
Y M % AMOUNT
1lb Quinoa, 4lb Pigeon Peas, Chick Peas
187 1 $0.00

2lb Premium Tea, Wagh Bakri

189 1 $0.00
285g Organic Fish N Fry Coating Mix
190 1 $0.00

192 2kg Sugar 1 $0.00

193 1kg Salt 1 $0.00
195 Assorted Asian Food 1 $0.00
Unknown Spice In A Tin Can
196 1 $0.00
Shoe Horn And Back Scratcher
197 1 $0.00

200 2x38in Area Rug 1 $0.00

Living Room
9 Throw Pillows 4 $0.00
3 Seater Couch 81"×36"×32"
10 1 $0.00

11 Love Seat 60"×36"×31" 1 $0.00

67 Rug 71"x24" 1 $0.00
69 Slices of cheese 7 $0.00
Great value whole kernel corn750g
70 1 $0.00

71 Ice 2 $0.00
Prescription for medicine
72 1 $0.00
Cracker Barrel Mozza Cheddar 320g
74 1 $0.00

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 CLAIM ID: 2304SK039
SCHEDULE OF LOSS CLAIM DATE: Apr 1, 2023
REPORT DATE: Apr 28, 2023
INSURED: Osman Ahmed Syed

AGE REPLACEMENT DEPRECIATION ACTUAL CASH REPLACEMENT BALANCE OF

NO. DESCRIPTION BRAND MODEL QTY PURCHASE PRICE COST VALUE VALUE INVOICE AMT. CLAIM
Y M % AMOUNT
75 Switz Sambosa Leaves 1 $0.00
76 Empty containers 3 $0.00
Hala minced beef (3 PCs)
78 3 $0.00

79 Chicken 3 Pieces 1 $0.00

80 Empty Containers 3 $0.00
Shana Original Paratha 400g
82 1 $0.00
Great Value Neapolitan Ice Milk 4L
83 1 $0.00

85 11 Eggs 11 $0.00
2- Bush’s Black Bean Fiesta 398 mL, 2- Great Value Dark Red Kidney Beans 540 mL, 1- Heinz Beans Red Kidney 398 mL

87 1 $0.00

Saskatoon Berry Jam 950 mL

89 1 $0.00
Kirkland Sunsweet Pitted Prunes 1.6 kg
90 1 $0.00
Kirkland Spanish Olives 1L
91 1 $0.00
No Name Soya Sauce 450 mL
93 1 $0.00
Dairyland Homogenized Milk 4L
94 1 $0.00
Unknown leaves, cheese, candy
96 1 $0.00
Happy Village Smyrna Figs 1.13 kg
99 1 $0.00

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 CLAIM ID: 2304SK039
SCHEDULE OF LOSS CLAIM DATE: Apr 1, 2023
REPORT DATE: Apr 28, 2023
INSURED: Osman Ahmed Syed

AGE REPLACEMENT DEPRECIATION ACTUAL CASH REPLACEMENT BALANCE OF

NO. DESCRIPTION BRAND MODEL QTY PURCHASE PRICE COST VALUE VALUE INVOICE AMT. CLAIM
Y M % AMOUNT
Dairyland Whipped Cream 225g
101 1 $0.00

103 Coca-Cola 2L 1 $0.00

Hershey’s Chipits Milk Chocolate Baking Pieces 270g
104 1 $0.00

105 Dill 1 $0.00

Supra vit vitamin C 1000mg 80g
107 1 $0.00
Knorr 2 Chicken Flavoured Bouillon Cubes 20g
108 1 $0.00

Kraft BBQ Sauce 455mL

110 1 $0.00
Rice In Glass Container
111 1 $0.00
Big Marble Farms Seedless Cucumber
112 1 $0.00

114 Heinz Mayonnaise 4L 1 $0.00

1- Kraft Crunchy Peanut Butter 1kg , 2- Compliments Smooth Peanut Butter

115 3 $0.00

Saskatoon Berry 360mL

116 1 $0.00
1- Apple, 3kg Potatoes
118 1 $0.00
Unknown Food In Container
119 1 $0.00

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 CLAIM ID: 2304SK039
SCHEDULE OF LOSS CLAIM DATE: Apr 1, 2023
REPORT DATE: Apr 28, 2023
INSURED: Osman Ahmed Syed

AGE REPLACEMENT DEPRECIATION ACTUAL CASH REPLACEMENT BALANCE OF

NO. DESCRIPTION BRAND MODEL QTY PURCHASE PRICE COST VALUE VALUE INVOICE AMT. CLAIM
Y M % AMOUNT
Philadelphia Whipped Original 227g
120 1 $0.00

Unknown Food In Plastic Bowl

121 1 $0.00

122 2- Pieces Chocolate 1 $0.00

126 Becel Margarine 427g 2 $0.00
Astro Original Natural Yogourt 750g
129 2 $0.00
Green Giant Whole Kernel Corn 341mL, Compliments Tomato Sauce 213 mL

132 2 $0.00

1-Atlantic Salmon , 2- Flaked Light Tuna 2- Unknown canned fish

136 1 $0.00

Great Value Pasta Sauce , Sweetened Condensed Milk

138 1 $0.00

139 Chilli pepper 1 $0.00

140 Unknown Food 1 $0.00
141 Carrot 1 $0.00
Knorr 2 Chicken Flavoured Broth Cubes 20g
142 1 $0.00

Heinz Tomato Ketchup 1.25 L

143 2 $0.00

188 Empty Boxes 3 $0.00

extension cable, 2-USB cables
191 1 $0.00

194 Craft 1 $0.00

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 CLAIM ID: 2304SK039
SCHEDULE OF LOSS CLAIM DATE: Apr 1, 2023
REPORT DATE: Apr 28, 2023
INSURED: Osman Ahmed Syed

AGE REPLACEMENT DEPRECIATION ACTUAL CASH REPLACEMENT BALANCE OF

NO. DESCRIPTION BRAND MODEL QTY PURCHASE PRICE COST VALUE VALUE INVOICE AMT. CLAIM
Y M % AMOUNT
Tablecloth 54”x 23”, lighter
198 2 $0.00

Totals: $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Any person who, fraudulently or willfully makes false, misleading, or exaggerated

statement or who conceals information for the purpose of presenting a claim is
acting in violation of the Statutory Conditions of their policy. This would lead to a
denial of the entire claim and may result in criminal prosecution.
DATE SIGNATURE OF INSURED

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