CLAIM NUMBER 
AFFIDAVIT OF NO INSURANCE

_________________________, __________________________, being	
                       Name                                        County, State

	Duly sworn deposed and says:

1.	That my name is ______________________________of

___________________________________________________`

___________________________________________________

2.	That I was involved in an automobile collision on ______
                                                                                            [date]
	at ___________________________________________.
                                  [location]

3.	As a result of that collision, I suffered bodily injuries.

4.	That I did not own an automobile on the date of this accident.

5.	That no member of the household (resident relative) in which I reside owns an automobile.

6.	That I have no automobile insurance or any other insurance which would pay any benefits to cover my bodily injuries.

7.	That I was not within the course of my employment at the time of the accident.

8.	I have no Uninsured/Under Insured Motorist Coverage

___________________
          [Signature]
Sworn to before me this _____day of
__________________, 20_________

_______________________________
                     Notary Public

Any person who, knowingly and with intent to injure, defraud, or deceive any insurance company files a statement of claim containing any false or misleading information commits insurance fraud, punishable by law.