West Virginia Code
Article 4. Rules and Pleading
§56-4-17. Form of Declaration or Count on Insurance Policy

A declaration or count on a policy of insurance, whether the policy be under seal or not, may be in effect as follows:
A ................ B ................complains of
C ................ D ................, who has been summoned to answer this: For that the defendant, by virtue of the policy of insurance herewith filed (or a copy of which is herewith filed), owes (here state the amount claimed under the policy) to the plaintiff for loss in respect to the property (or subject) insured by said policy, caused by (here insert the cause of loss in general terms, for example: By fire, by the damages of navigation, or otherwise, according to the fact) on or about the .......... day of ............., in the year ........., at (or near to) ................., (stating the place at or near to which the loss occurred).
If the declaration or count be on a life policy, then it shall be sufficient to follow the above form in effect down to and including the word, "plaintiff" and add thereto in effect as follows:
Because of the death of E.F., whose life was insured by said policy, and who died on or about the .......... day of .........., in the year ........., at (or near to, stating the place where his death occurred) .................; or, if the fact be so, the plaintiff may state in the declaration or count that the time or place where the loss or death occurred is unknown to him giving in general terms such information as may be in his power in respect thereto. Nothing contained in this section shall render insufficient in law any declaration or count which would be sufficient if this section had not been passed.

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