Affidavit of Insurance Coverage Servicing

Full Name *

Insurance Name

Insurance Address

Phone Number

Policy Number

Expiration Date

Driver's License

Expiration Date

I hereby certify that I have a current insurance policy with the above named company for coverage on my vehicle. I also understand that it is my responsibility to carry the level of coverage required (Personal Injury Protection) and recommended by my insurance carrier the purpose of which I am using my personal vehicle. I will notify All Support Servicing of any changes made to the above coverage within 15 days of such change.

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