No Insurance Complaint Affidavit Form
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1
2ARLINGTON POLICE DEPARTMENT
(assigned by Traffic Division)
Case Number
_____________
NO INSURANCE COMPLAINT AFFIDAVIT
Accident Report Number (Police) ________________
DRI VER
(SUSPECT) INFORMATION
LAST NAME
FIRST NAME
MIDDLE INITIAL
DATE OF BIRTH or approx age
RACE
SEX
HEIGHT
WEIGHT
DRIVER’S LICENSE NUMBER
STATE
ADDRESS
CITY
STATE
ZIP CODE
HOME PHONE NUMBER
BUSINESS PHONE NUMBER
SUSPECT VEHICLE INFORMATION
MAKE
MODEL
TYPE
COLOR/COLOR
LICENSE PLATE NUMBER
LICENSE PLATE STATE
SUSPECT INSURANCE INFORMATION
INSURANCE COMPANY NAME
POLICY NUMBER
AGENT’S NAME
PHONE NUMBER
MY INFORMATION
LAST NAME
FIRST NAME
MIDDLE INITIAL
DATE OF BIRTH
ADDRESS
CITY
STATE
ZIP CODE
HOME PHONE NUMBER
BUSINESS PHONE NUMBER
MY INSURANCE INFORMATION
INSURANCE COMPANY NAME
POLICY NUMBER
AGENT’S NAME
PHONE NUMBER
“My complaint is based on the following facts. I was involved in a traffic accident with the suspect described
above on [date] ______________________________ at ____________
a.m.
p.m. in Arlington
.
The accident occurred at [address] ______________________________________________________________.
The suspect’s vehicle was traveling [direction] ____________________________________________________________.
The suspect did not have sufficient proof of motor vehicle liability insurance coverage in effect at the time of the
accident, as required by Texas’ mandatory insurance laws. [Explain how you learned this. Use back of page as needed.]
Accident Report # (if Police completed one) _____________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
This information is true and correct to the best of my knowledge.”
_________________________________________________
SIGNATURE
SUBSCRIBED AND SWORN TO BEFORE ME by the said _______________________________________________,
on this the _______ day of ____________________, ___________.
_________________________________________________
(seal)
NOTARY PUBLIC IN AND FOR THE STATE OF TEXAS
APD 12-02
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