Get Affidavit Of No Other Insurance Form

This guide provides you with clear, step-by-step instructions on how to complete the Affidavit Of No Other Insurance Form online. By following these steps, you will ensure that all necessary information is accurately provided, streamlining the filing process.

Follow the steps to fill out the Affidavit Of No Other Insurance Form online

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide your claim number at the top of the form.
3. In the first section, fill in the state and county where you are filing.
4. Enter your full name in the designated field.
5. Complete your current address by providing details about your residence.
6. Add your home phone number in the specified section.
7. Fill in your date of birth (DOB) accurately.
8. If applicable, provide your Social Security number (SSN) or indicate 'none' if you do not have one.
9. Input your Individual Taxpayer Identification Number (ITIN) or enter 'none' if you do not possess one.
10. Indicate your gender by selecting the appropriate option and specify whether you are a Medicare beneficiary.
11. If you have a driver’s license, provide the details, including the state and number.
12. On the date of the accident, indicate your residence and provide your driver’s license details if it has changed.
13. List all other residents in your household at the time of the accident, including their names, dates of birth, social security numbers, driver’s license information, states, and their relationship to you.
14. Check each applicable option regarding your insurance status on the accident date.
15. Read and certify the statements made in the affidavit by signing in the designated area.
16. Finally, ensure to complete the area for notarization, including the date.
17. Once all sections are completed, save your changes, and choose to download, print, or share the form as needed.

Start filling out your Affidavit Of No Other Insurance Form online today.