Form- Affidavit of Non-Ownership

Please see the attached Non-ownership of Motor Vehicle Affidavit. It is to be used when a patient is treating at your office and wants to submit PIP bills through another person’s insurance policy.

Click here to see a nice PDF form that you can download for free

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 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.

Sincerely,

Abraham S. Ovadia, Esq.

abe@wesetthestandards.com

STATE OF FLORIDA

COUNTY OF ___________________

AFFIDAVIT OF NON-OWNERSHIP

After being duly sworn, I state upon personal knowledge that:

  1. I am ________________________; I am over the age of 18; and I am legally competent.
  1. I was involved in a motor vehicle collision on or about _____________________.
  1. I did not own a motor vehicle at the time of the above mentioned collision. I do not live with anyone who owns a motor vehicle and I am not provided coverage by any other No-Fault Insurance Policy for the injuries sustained in the motor vehicle collision on the above-referenced date.

Further Affiant Sayeth Naught.

________________________

Patient Signature

­________________________

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___.

________________________

Notary Public

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