Fillable CSA Affidavit Of No Insurance CSA_Adavit of No insurance.5.5

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CSA Affidavit Of No Insurance CSA_Adavit of No insurance.5.5

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Afdavit of No Insurance: Medical_15698_0414
AFFIDAVIT OF NO INSURANCE
I/we, _____________________________ hereby declare under penalty of perjury that I/we
do not have any other valid and collectible insurance or indemnity coverage, including,
but not limited to, primary/supplemental medical insurance, Medicare, or other travel
insurance policies that were in effect during the covered trip.
_______________________________________ _________________________
Signature Date
_______________________________________
Print Name
_______________________________________ _________________________
Signature Date
_______________________________________
Print Name
_______________________________________ _________________________
Witness Signature Date
_______________________________________
Print Name
P.O. Box 939057 | San Diego, CA 92193-9057 | (800) 541-3522 | claims@CSATravelProtection.com
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CSA Affidavit Of No Insurance CSA_Adavit of No insurance.5.5

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Completed 13 June 2020

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