Application For Benefits - Personal Injury Protection Page 3
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3HEALTH / NO-HEALTH INSURANCE AFFIDAVIT
INSURANCE CO:_____________________
FILE / CLAIM #: _____________________
DATE OF LOSS: _____________________
INSURED NAME: ____________________
SECTION I - BENEFITS INFORMATION
NAME:__________________________________
INSURANCE COMPANY: ______________________________
SUBSCRIBER (If not you): _________________________
SUBSCRIBER ID: _____________________________
GROUP / POLICY NUMBER: ______________________________
SIGNATURE: ___________________________________________
DATE: ________________________
SECTION II - ADDITIONAL BENEFITS INFORMATION (If applicable)
NAME:__________________________________
INSURANCE COMPANY: ______________________________
SUBSCRIBER (If not you): _________________________
SUBSCRIBER ID: _____________________________
GROUP / POLICY NUMBER: ______________________________
SIGNATURE: ___________________________________________
DATE: ________________________
SECTION III - STATEMENT OF NO HEALTH INSURANCE (If applicable)
I CERTIFY THAT I DO NOT HAVE ANY ACCIDENT AND / OR HEALTH INSURANCE AVAILABLE TO ME THROUGH MY
OWN POLICY OR THAT OF A HOUSEHOLD MEMBER.
SIGNATURE ___________________________________________
DATE: ___________________________
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