Form- Affidavit of Inoperability
Please see the attached Affidavit of Inoperability. It is to be used when a patient is treating at your office, owns a motor vehicle, and goes through another person’s PIP insurance policy.
This form should be used to “CYA” in the event the insurance company claims the patient owned a motor vehicle and should have used (or had) their own PIP insurance. It should not be sent to the insurance company unless they deny your PIP bills.
Because patient’s can be hard to reach after they stop treating it is best to get the patient to complete this affidavit while they are still treating. Also, please make sure they get this form notarized.
Abraham S. Ovadia, Esq.
STATE OF FLORIDA
COUNTY OF ___________________
AFFIDAVIT OF INOPERABILITY
After being duly sworn, I state upon personal knowledge that:
- I am ___________________________; I am over the age of 18; and I am legally competent.
- I was a driver / passenger / pedestrian (CIRCLE ONE) involved in a motor vehicle collision on ___________________________.
- I own a motor vehicle described as:
- The above motor vehicle is inoperable because (BE AS SPECIFIC AS POSSIBLE):
5. The above motor vehicle has been inoperable since _________________.
- I do not own any other motor vehicle for which security is required under Florida Statutes Chapter 627 nor do I live with a relative who owns such a vehicle.
Further Affiant Sayeth Naught.
Print Patient Name
Sworn to before me, a Notary Public of this State, by __________________________, who is/not personally known to me and presented ___________________________ as identification this _____ Day of _____________________, 20___.