Free Affidavit of Compliance with the Insurance Law - New York

CIVIL COURT OF THE CITY OF NEW YORK County of

Index No.: AFFIDAVIT OF COMPLIANCE WITH THE INSURANCE LAW

State of New York, County of

ss: , being duly sworn, deposes and says:

I am over 18 years of age and I am the Claimant in this action. On State of New York in that I 1. served the Superintendent of the State Insurance Department with the original Summons in this matter along with payment of the required fee, and I also I complied with § 1213 of the Insurance Law of the

2. mailed Notice of this action to the Defendant, along with a copy of the Summons in the matter, by Certified Mail, Return Receipt Requested. Proof of such mailing to the Defendant is documented by: The signed and dated Return Receipt form which is annexed herewith. The original envelope annexed herewith, bearing the notation by the Postal Service that the mail was refused by the Defendant.

Signature of Deponent

Print Name of Deponent Sworn to before me this Notary Public day of 20

CIV-GP-74-B(Revised 1104)-i
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