Affidavit Of No Health Insurance Form

This affidavit is used to disclose health insurance coverage that is available for children.

Affidavit of no health insurance form. If your settings prevent this you may also copy and paste join masshealth member forms. It is also used to determine child support. Affidavit of no insurance i due hereby swear that i have no medical health insurance print name for payment of medical bills associated with my injury sustained during my participation in intercollegiate athletics. Applicant or member printed name.

I do not receive any income at this time. An affidavit of no insurance is a written statement made by a person verifying that he does not have liability insurance covering a claim or lawsuit filed against him for injuries or property damage. Social security number ref id. Various forms used by masshealth members.

However this only happens if no objection is made to its use and if it is subject to cross examination. Start a free trial now to save yourself time and money. The affidavit is a legal document signed under oath or an affirmation. Microsoft word affidavit of no insurance 032008 doc author.

Fill out securely sign print or email your maryland health connection affidavit form instantly with signnow. Available for pc ios and android. Maryland healthcare connection forms pdf. Brian french created date.

The most secure digital platform to get legally binding electronically signed documents in just a few seconds. Check local court rules to determine when this form must be filed. An affidavit form may also be used as evidence in administrative and quasi judicial proceedings. Sign up for email notification when new or updated member forms are posted to the website.

Affidavit to verify zero income step 1 tell us about yourself please print. Often the injured person can obtain an affidavit of no insurance from the liable party and pursue other potential insurance to cover her damages. I certify that the foregoing statements made by me are true. Last name last 4 numbers of.

First name middle initial. 3 26 2008 2 25 30 am. It must be filed if there are minor children of the relationship. Because an affidavit is a legal statement it verifies your personal information for identification purposes.

On the date the accident occurred i personally did not own an automobile with liability insurance coverage that would afford me personal injury protection no fault benefits. Insurance carrier for coverage of medical services. Step 2 read and sign this form.