Sworn Affidavit

Affidavit - General Loss

Sworn Affidavit

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE MATERIAL FACT THERETO COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. PREMIER INSURANCE SERVICES LLC WILL ALERT LAW ENFORCEMENT AND STATE INSURANCE DEPARTMENT(S) IN THE EVENT OF INSURANCE FRAUD AND CLAIMANTS MAY BE SUBJECT TO ARRESTS, FINES, DISCIPLINARY ACTION AND/OR OTHER RAMIFICATIONS.

Premier Claims Handler(Required)

Premier Claim No.

Personal Information

Name(Required)

First Last

Email(Required)

Phone(Required)

Date of Birth(Required)

Drivers License / Identification No.(Required)

Company(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Loss Information

Date of Loss(Required)

Type of Loss(Required)

Ex. Armed Robbery

Police Report Reference Number(Required)

Ex. Miami-Dade Police Department Report NO. 21-021536-283

Description of Loss(Required)

Please insert complete details including dates, times, reference numbers, person(s) involved.

Ex. On June 2, 2021, I, James Smith, was traveling in my personal vehicle on Biscayne Blvd. in Miami, FL when I stopped at the Exxon gas station at 1785 Biscayne Blvd at 1:23 PM. I exited my vehicle and walked to the pump to begin fueling when two men wearing masks held me up at gunpoint and I was forced to hand over my Rolex Daytona Everrose Gold watch (Model # xxxxx Serial # xxxxx). The suspects fled on foot and I immediately called 911 from my mobile phone to report the incident. Police arrived at the scene approximately 15 minutes later, obtained statements from witnesses and myself and issued Incident No. 21-021536-283 to the armed robbery. The Detective assigned to my case in Detective Garcia.

Please Upload All Claims Documents

Some examples are:

Photo ID, Police Report, Photos of Items Lost, Invoices, Memos, Air WayBill, Shipping Label, Claims Forms, Letters, Photographs, Travel Documents

Drop files here or

Max. file size: 32 MB.

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