DIY Legal Forms

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Uninsured Motorist Sworn Statement In Proof Of Loss

STATE OF -------)

COUNTY OF ------)

I hereby claim under the uninsured motorist coverage provided to [Date], under policy [Number], policy period commencing [Date], concluding [Date], the total sum of [$-------] as the full amount of uninsured motorist losses, including the following expenses incurred in relation to said accident:

See exhibit 1 attached hereto

Place of accident: Date of accident: [Date]

The persons or company who I contend is legally liable to me for my injuries is:




STATE OF -------)

) ss: [date]

COUNTY OF ------)

On [Date] before me, [Name of Notary], notary, personally appeared [Name of Person(s) Involved], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

Witness my hand and official seal.


[Name of Notary Public]

My commission expires: [date]


[Important: Do not sign the Release agreement until agreement with the Insurance Company as to settlement]


In consideration of the sum of [$------], received from Insurance Company, I hereby acknowledge full satisfaction and release all claims and demands against the Insurance Company, by reason of the accident, and agree to take such as action as may be necessary to recover damages from the person or entity who is liable, or others, through legal counsel chosen by Insurance Company, at the expense of the Insurance Company.

I agree to fully reimburse the Insurance Company from any recovery made, for its payments herein, after the deduction of the expenses of suit, including attorney's fees, the full amount of the payment, plus interest at the rate of percent from date of payment, to the extent of recovery. I further agree that the Insurance Company shall have the sole right to authorize settlement of the claim, and that I may not agree to a settlement of the claim without the prior authority of the Insurance Company.