**PROPERTY SCHEDULE**

| TYPE AND DESCRIPTION | CODES | AMOUNT | INTERIM |
|----------------------|-------|--------|---------|
|                      |       |        |         |

**CANADIAN DECLARATION**

**INSURANCE COMPANY OF NORTH AMERICA**

**CASUALTY SCHEDULE**

**NAME:** [Name]
**ADDRESS:** [Address]
**POLICY NO.:** [Policy Number]
**DATE:** [Date]

**PROPERTY SCHEDULE**

| TYPE AND DESCRIPTION | CODES | AMOUNT | INTERIM |
|----------------------|-------|--------|---------|
|                      |       |        |         |