SI-04 (Revised 09/2018)
Central Services Division
Vehicle Programs
555 Wright Way
Carson City, Nevada 89711
(775) 684-4491
Email: DMVSelfInsurance@dmv.nv.gov
AFFIDAVIT
SELF-INSURER’S USE OF ADJUSTING COMPANY TO SETTLE CLAIMS
Self-Insurance Applicant or Certificate Holder
Assigned Certificate Number
(If new applicant, please leave this space blank.)
In accordance with NAC 485.110, “A self-insurer may settle its own claims or use the services of an adjusting company
licensed in accordance with chapter 684A of NRS to settle claims on its behalf. If the self-insurer uses an adjusting company to
settle claims, an affidavit must be included with the reports submitted pursuant to subsection 1 which lists all companies that
settled claims during the reporting period.”
I, the undersigned, being duly sworn, depose and state that the following adjusting company/companies settled
claims on behalf of the above-listed self-insurance applicant or self-insurance certificate holder during the reporting
period beginning on and ending on .*
*NOTE:
If more than one adjusting company settled claims within the 3-year reporting period, a separate and complete affidavit must be submitted for each year.
ADJUSTING COMPANY/COMPANIES
USED TO SETTLE CLAIMS DURING THE REPORTING PERIOD
DATES CLAIMS SETTLED
DURING REPORTING PERIOD
Adjusting Company’s
Name
Adjusting Company’s
Address
Adjusting
Company’s
Telephone
Beginning
Date
Ending Date
NOTE: TO BE SIGNED ONLY BY INDIVIDUAL, SOLE PROPRIETOR, PARTNER, OR OFFICER OF THE CORPORATION.
I hereby certify all statements made in this report are true and correct. I fully understand false statements are cause
for cancellation of the Certificate of Self-Insurance. I understand that this affidavit must be filed annually no earlier
than 60 days before and no later than 15 days before the date of expiration of the certificate of self-insurance.
Printed Name Title
Signature Date
NOTARIZATION:
State of County of
I certify that on the date set forth below, the individual named above did appear
personally before me and that I did identify this individual. The statements on
this document are subscribed and sworn to before me by the endorsee on this
day of , .
Notary Public Signature:
My Commission Expires:
