Florida Insurance Affidavit

In the case of an insured person wanting to certify that he/she has personal injury protection, the following form affidavit has to be executed.

Extracted Text for Proper Search

FLORIDA INSURANCE AFFIDAVIT	 	
 
Under penalty of perjury, I 	__________________________________________ 	certify that I have 	 	 	 	 	 	 	 	(Name of Insured)	 	 
Personal 	Injury P	rotect	ion	, Property Damage Liability	, and, when required,	 Bodily Injury Liability 	 	
 
Insuran	ce currently in effect with 	__________________________________________	___	 under	 	 	 	 	 	 	         	 	     	(Name of Insurance Company)	 	
 
____	___________________	__	_ _____________	_______	 covering th	e following motor vehicle:	 	                   	    (Policy Number	) 	         Company 	Code 	Number (5 digits)	 	
 
_________________________________________________________________________________________________________	 	          	Year	                             Make	                                                                 	                    	Vehicle Identification Number	 	
 
This insurance company is licensed to issue insurance policies in Florida.  	I understand that my 	
driver license, license plate(s) and registration(s) will be suspended effective from the registration 
date,	 if the insurer denies that 	this policy is in force.	 	
 
 
 	 	 	 	 	 	        	_______________________________________	 	
 	 	 	 	 	 	 	 	       	Signature of Insured	 	
 
WARNING:   	 GIVING FALSE INFORMATION IN ORDER TO OBTAIN A VEHICLE REGISTRATION 
CERTIFICATE IS A CRIMINAL OFFEN	SE UNDER FLORIDA LAW.  ANYONE GIVING 	
FALSE INFORMATION ON THIS AFFIDAVIT IS SUBJECT TO PROSECUTION.	 	
 HSMV 83330 (Rev. 09/09) 	 	 	 	 	www.flhsmv.gov