Free Affidavit of Employment for Insurance Claims Template
Affidavit of Employment for Insurance Claims
State of Texas
County of Irving
I, [YOUR NAME], being duly sworn, depose and say:
1. Affiant Information
1.1. Name: [YOUR NAME]
1.2. Address: Irving, TX 75038
1.3. Position: School Administrator
1.4. Employer: [YOUR COMPANY NAME]
1.5. Contact Information: [YOUR COMPANY NUMBER]
2. Employment Verification
2.1. Employee Name: Naomi Ortiz
2.2. Employee Position: Math Teacher
2.3. Employee ID: A123456
2.4. Date of Employment: August 15, 2060
2.5. Current Employment Status: Full-Time
3. Employment History and Job Details
3.1. Work Schedule: Full-Time, averaging 40 hours per week
3.2. Job Responsibilities: Responsible for teaching high school mathematics, preparing lesson plans, grading assignments, and supporting student learning outcomes.
3.3. Compensation: Employee’s compensation is approximately $60,000 annually.
4. Verification of Insurance Coverage
4.1. Insurance Provider: ForBiz
4.2. Policy Number: BS123456789
4.3. Coverage Start Date: August 15, 2060
4.4. Coverage Status: Employee is currently covered under the employer-provided insurance.
5. Reason for Affidavit
This affidavit is prepared at the request of Naomi Ortiz in support of their insurance claim with ForBiz. This affidavit is intended to confirm the employee’s current employment status, employment details, and insurance coverage as outlined above.
6. Affirmation
I hereby affirm under penalty of perjury that the above information is true and accurate to the best of my knowledge and belief.
Dated: October 31, 2064
[YOUR NAME]
School Administrator
[YOUR COMPANY NAME]
SWORN AND SUBSCRIBED before me on this 31st day of October, 2064.
Oman White, Notary Public
My Commission Expires: March 15, 2066
Seal: [NOTARY SEAL]
