Ccl-101c - Sworn Affidavit (State Of Wisconsin) printable pdf download

Ccl-101c - Sworn Affidavit (State Of Wisconsin)

ccl-101c (02/07)

AFFIDAVIT

STATE OF WISCONSIN}

}

______________ County}

________________________, being first duly sworn, on oath deposes and says

(Agent)

that he/she is the agent of the__________________________________, insurer

(Company name)

on the attached certificate issued to ___________________________________.

(Legal entity of Insured)

Affiant further deposes and says that no officer, official or employee of the City of

Milwaukee has any interest, directly or indirectly, or is receiving any premium,

commission, fee or any other thing of value on account of the sale of furnishing of

said insurance certificate.

_______________________________

(Signature of above Agent)

Subscribed and sworn to before me

this ______day of ___________,20_____.

____________________________________

Notary Public-State of Wisconsin

My Commission expires_________________

Notary Seal Must Be Affixed.

Please note the following requirements:

1) The name and signature of the agent or authorized representative must be

included and match the agent or authorized who signed the insurance

certificate.

2) The full name of the Insurance Company must be listed and match exactly

the Insurance Company’s name from the insurance certificate.

3) The date the notary signed and dated the affidavit must be the same as the

date of the insurance certificate.

4) The Notary must sign, date and stamp the form.

5) The correct county and state must be listed. (If outside the state of

Wisconsin, please cross out Wisconsin and write/type in correct state.)

Ccl-101c - Sworn Affidavit (State Of Wisconsin)