Affidavit Of No Insurance Form printable pdf download

AFFIDAVIT OF NO INSURANCE

I, ____________________________________________ of ___________________________________________________________

(Full address on accident date)

______________________________________________ ____________________________________________________________

(Home and Employer telephone number)

was involved in an accident on ______________ at __________________________________________________________________

(Date)

(Exact location of accident)

_______________________________________________ when I was a _________________________________________________

(Driver/Passenger (where seated)/Pedestrian)

in a vehicle, or in contact with a vehicle, owned/operated by ___________________________________________________________

(Name/Address of Owner/Operator)

As a result of this accident, I sustained personal injury. On the above date, I did not own or lease a motor vehicle, nor did I reside with

any relative who owned or leased a motor vehicle.

List all residents of your household by name, age, and relationship

(Use additional sheet if necessary)

Name

Date

Relationship

Own or Lease

If Yes, Insurer

Policy

Of Birth

A Vehicle?

Number

_______________________ ____________ ________________

Yes____No____

_____________

_______________________ ____________ ________________

Yes____No____

_____________

_______________________ ____________ ________________

Yes____No____

_____________

_______________________ ____________ ________________

Yes____No____

_____________

_______________________ ____________ ________________

Yes____No____

_____________

I make this statement to compel Citizens United Reciprocal Exchange to pay me personal injury protection or medical expense

benefits. I understand that any person who knowingly files a statement of claim containing any false or misleading information is

subject to criminal and civil penalties. I hereby request an application for PIP or medical expense benefits.

(X)_________________________________________________________

Driver’s License #: __________________________ State: ____________

(If none, so indicate)

State of

)

ss.

County of

)

On this ______________day of ________________, 20______, before me personally appeared ______________________________

to me known to be the person _____________________ described herein, and who executed the foregoing instrument and _________

acknowledged that ____________________________________ voluntarily executed the same.

________________________________________________

Notary Public

My term expires _____________________________________

Affidavit Of No Insurance Form

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