Statement of Fact Form

July 14, 2011

When a person intends to register a car, apply for insurance or for any graduate/undergraduate program and in other such conditions it is mandatory for the applicant to fill a statement of facts form which provides accurate and factually correct information about an applicant. The statement of Fact form contains all the personal and other related details of an individual.

Sample Statement of Fact Form

Personal details:

Full name: __________________________. Security Number ____________

Address: ____________________City _____________State: ___________Zip: _______

Phone: ________________Email: _________________Fax: ________________________

Age: ________________    No. of Family Members: ________________

Date of Birth: ________________

Employer: _________________________________________

Policy No: ________________                               Insured: ________________

Insurance start date: ________________                        Insurance End date: ________________


Download Statement of Fact Form in Word Format

Underwriter: ________________

Insured business: ________________

Other Details (tick ‘yes’ or ‘no):

Are there any ongoing legal disputes or disputes related to contracts?  Yes               No

Have you ever been declared bankrupt or insolvent?                       Yes              No

Have you suffered from any major illnesses in the recent past?         Yes        No

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