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Eadvocate4you Doc Templates Insurance Claim Affidavit Template

This affidavit is submitted by a policyholder to claim insurance benefits for a loss covered under their policy. It includes details about the policy, the incident leading to the claim, and an affirmation of the truthfulness of the statements made. The deponent also commits to complying with legal proceedings if any discrepancies arise.

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lalaine.salvador
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39 views2 pages

Eadvocate4you Doc Templates Insurance Claim Affidavit Template

This affidavit is submitted by a policyholder to claim insurance benefits for a loss covered under their policy. It includes details about the policy, the incident leading to the claim, and an affirmation of the truthfulness of the statements made. The deponent also commits to complying with legal proceedings if any discrepancies arise.

Uploaded by

lalaine.salvador
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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AFFIDAVIT FOR CLAIMING INSURANCE

[Deponent Details]:

1. That I am the deponent herein and hence, I am fully acquainted with the
facts of this affidavit.
2. That I am a citizen of India.
3. That I am the policyholder under [Type of Insurance Policy] policy no.
[Policy Number], issued by [Insurance Company] on [Date of Issuance of
Insurance Policy] with a coverage amount of ₹ [Sum Assured under the
Insurance Policy] ([Sum Assured under the Insurance Policy In Words]).
4. That this affidavit has been made to support my claim for insurance benefits
due to an incident that has caused loss/damage covered under the policy.
5. That on [Date of Incident/Reason for which insurance claimed] at [Time of
Incident/Reason for which insurance claimed], [Brief Description of the
Event].
6. That consequently, I am filing a claim for ₹ [Amount of Claim] ([Amount
of Claim in Words]) under the terms and coverage of the aforementioned
policy.
7. That to support my claim, I am submitting the required documents, including
the policy document: [Supporting Documents].
8. That the statements made in this affidavit are true and correct to the best of
my knowledge and belief. Nothing material has been concealed, and no part
of it is false.
9. That the claim made is genuine and no material information has been
concealed or misrepresented. In the event of any discrepancy, I undertake to
comply with any legal or police related proceedings.
Deponent

VERIFICATION:-

I, the above-named deponent, do hereby verify at [City where affidavit is


executed], [State where affidavit is executed] on [day] of [month] [year],
that the contents of my above affidavit are true and correct to the best of my
knowledge. No part of it is false, and nothing material has been concealed
therein.

Deponent

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