FLORIDA INSURANCE AFFIDAVIT
FLORIDA INSURANCE AFFIDAVIT
Under penalty of perjury, I __________________________________________ certify that I have
(Name of Insured)
Personal Injury Protection, Property Damage Liability, and, when required, Bodily Injury Liability
Insurance currently in effect with _____________________________________________ under (Name of Insurance Company)
__________________________ ____________________ covering the 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 OFFENSE UNDER FLORIDA LAW. ANYONE GIVING
FALSE INFORMATION ON THIS AFFIDAVIT IS SUBJECT TO PROSECUTION.
HSMV 83330 (Rev. 09/09) www.flhsmv.gov
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