Claimant Affidavit Form

CLAIMANT AFFIDAVIT FORM

This Affidavit is made this day of , by Claimant: , residing at , telephone , email , in relation to Claim Number: against Respondent: , with principal address at .

RECITALS

WHEREAS, Claimant contends that events occurred giving rise to a claim for loss, damage, expense or liability as described herein; and

WHEREAS, Respondent is alleged to be responsible for all or part of the loss and has been provided notice of the claim; and

WHEREAS, Claimant submits this Affidavit to set forth a sworn statement of facts, itemize claimed amounts, and identify supporting evidence in support of the claim referenced above.

NOW THEREFORE, in consideration of the foregoing recitals and the mutual provisions contained herein, the undersigned affiant hereby states under oath as follows:

1. DEFINITIONS

For purposes of this Affidavit, "Claimant" means the person identified as claimant_name and any authorized representative signing on behalf of that person; "Respondent" means the party identified as respondent_name; "Claim" means the loss, damage, expense or liability described in this document and supporting attachments.

2. STATEMENT OF FACTS

2.1 Date of Incident: / /

2.2 Location of Incident:

3. SUPPORTING DOCUMENTS

Claimant affirms that the following documents are attached or will be provided upon request (check all that apply and list exhibit identifier where applicable):

Police report (Exhibit: )

Photographs (Exhibit: )

Invoices/Receipts (Exhibit: )

4. DECLARATION AND OATH

I, the undersigned Claimant, declare under penalty of perjury under the laws of the governing jurisdiction that the foregoing statements and the attached documents are true and correct to the best of my knowledge, information and belief; that I am the person entitled to assert the claim set forth herein; and that I have authority to execute this Affidavit.

I understand that knowingly making a false statement in an affidavit may subject me to criminal penalties and civil liability.

5. REPRESENTATIONS AND WARRANTIES

Claimant represents and warrants that (a) no other party has been paid or compensated for the loss claimed herein except as disclosed in writing; (b) all amounts claimed are actual and documented; and (c) Claimant will cooperate in any investigation or proceeding relating to this claim.

6. NOTICES

Notices given in accordance with this section shall be effective upon personal delivery or three (3) days after deposit in the United States mail, postage prepaid, addressed to the notice addresses set forth above.

7. AMENDMENTS; WAIVER

This Affidavit may be amended or supplemented only by a written instrument signed by the party to be charged. No failure or delay by any party in exercising any right hereunder shall operate as a waiver of such right.

8. GOVERNING LAW

This Affidavit shall be governed by and construed in accordance with the substantive laws of the state or jurisdiction in which the Respondent's principal address is located, without regard to conflict of law principles.

9. SEVERABILITY

If any provision of this Affidavit is held to be invalid or unenforceable, the remaining provisions shall continue in full force and effect.

10. ENTIRE AGREEMENT; COUNTERPARTS

This Affidavit, together with any exhibits and attachments expressly incorporated herein, constitutes the entire sworn statement of Claimant with respect to the matters contained herein. This Affidavit may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument.

11. SUBMISSION

By signing below, Claimant confirms that the statements in this Affidavit are true to the best of Claimant's knowledge and belief and acknowledges that this Affidavit may be relied upon by Respondent, insurers, investigators, and any tribunal or adjudicatory body considering the claim.

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