Insurance Broker Affidavit Form

Insurance Broker Affidavit Form
Use this form to submit an affidavit related to an insurance broker matter, including broker details, policy reference information, the facts being affirmed, and signature.
Broker and Business Information
Broker Full Name
First NameLast Name
Brokerage / Company Name
Job Title / Role
Business Email Address
example@example.com
Business Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Office Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Affidavit and Policy Reference Details
Affidavit Title or Reference Number
Client or Insured Party Name
Policy Number or Policy Reference
Insurer or Company Name
Date of Incident or Matter
MonthDayYear
Date
Affirmed Facts and Supporting Information
Statement of Facts Being Affirmed
Reason for Affidavit / Purpose of Submission
Broker’s Relationship to the Matter
Other
Are Supporting Documents Attached?
Supporting Attachment(s)
Cancelof
Attestation, Signature, and Submission Details
Declaration and Attestation
Signer Name
Signature
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Signing Date
MonthDayYear
Date
Notary Notes
Should be Empty: