Florida Insurance Affidavit – Escambia County, FL

The Florida Insurance Affidavit is a sworn statement, published by the Escambia County Tax Collector, in which the insured certifies under penalty of perjury that Personal Injury Protection, Property Damage Liability and, when required, Bodily Injury Liability insurance is in effect on a specific motor vehicle.

The form records the name of the insured, the date the insurance is in effect, the name of the insurance company, the policy number, the five-digit company code, and the year, make and Vehicle Identification Number of the vehicle. The insured also states that the insurance company is licensed to issue policies in Florida.

By signing, the insured acknowledges that the driver license and license plate(s) will be suspended effective from the registration date if the insurer denies that the policy is in force. A printed warning states that giving false information in order to obtain a vehicle registration certificate is a criminal offense under Florida law and that anyone giving false information on the affidavit is subject to prosecution.

The lower part of the page is the Escambia County Tax Collector Insurance Notice. It says proof of Florida insurance must be verifiable as of the date of signing, and it ends with a line for the state where you are insured, the tag number, and your initials and the date. The form's footer places it among the Tax Collector's Motor Vehicles forms and prints the revision as Rev - 04/13/2020.

The insured person named on a motor vehicle insurance policy signs this affidavit to certify that the coverage described on the form is in effect on the vehicle listed. The form is issued by the Escambia County Tax Collector, and its warning refers to giving information in order to obtain a vehicle registration certificate.

Points the form itself makes about who can sign and when:

• The signer is the Name of Insured, and the insured signs under penalty of perjury.
• The policy must cover Personal Injury Protection and Property Damage Liability, plus Bodily Injury Liability when it is required.
• The insurer must be licensed to issue policies in Florida.
• Coverage must be verifiable as of the date you sign. The notice says insurance purchased or binders issued at a later date will not prevent a sanction on your driver license.
• Courtesy coverage for replacement vehicles should not be relied upon to sign the statement.

The form says nothing about a representative signing for the insured; the signature line is for the insured.

The form ties itself to the moment you sign it. The Tax Collector's insurance notice says proof of Florida insurance must be verifiable as of that date to avoid suspension of your driver license, license plate(s) and registration(s), so complete it when you can show coverage that is already in force.

Insurance purchased or binders issued at a later date will not prevent a sanction on your driver license. Insurance purchased online or by phone must be bound on or before the date you sign. The warning on the form links the affidavit to obtaining a vehicle registration certificate; no separate deadline or validity period is printed on it.

The form prints no mailing address, portal, appointment rule or fee, so it names no submission channel of its own. It is a form of the Escambia County Tax Collector (its footer places it among the Motor Vehicles forms), and the warning on it refers to obtaining a vehicle registration certificate. Ask the Escambia County Tax Collector how and where it wants the signed affidavit delivered; the official PDF is published at https://escambiataxcollector.com/wp-content/uploads/2020/04/Aff-Insurance-Affidavit.pdf. Sign the form yourself and initial and date the notice before you deliver it. FillingPDF lets you fill out and download the PDF; submission follows the Escambia County Tax Collector's channels.