DECLARATION OF JOHN DOE
I, John Doe, hereby declare as follows:
1. That on or about March 1, 2017, I was the driver and registered owner of a 2015 Subaru vehicle, with a California License Plate.
2. That on or about March 1, 2017, my vehicle was involved in an automobile collision in Los Angeles County, California with another vehicle, wherein Mr. Tom Smith, was seriously injured.
3. That I understand that Mr. Tom Smith is making claims against me for damages (including but not limited to medical expenses, loss of wages & pain and suffering).
4. That I understand that if I were found to be liable for the incident in this or any other judicial proceeding and a verdict and/or judgment were entered against me, my insurance policy with P. Insurance Company may not cover all of the losses that Mr. Tom Smith, is claiming against me.
5. That I understand that my P. Insurance Company policy in effect at the time of the subject incident provided bodily injury limits of $__10-30k______ per person and $__15k______ per accident.
6. That I am representing to Mr. Tom Smith, and his attorneys that I am not aware of, do not own, am not named and cannot be construed as an insured on any other insurance policy whatsoever that may cover any of the losses that Mr. Tom Smith is claiming against me and that there is, in fact, no other policy (other than the P. Insurance Company) which may cover the claims of Mr Tom Smith. I am further representing that I do not own, am not named and cannot be construed as an insured on any umbrella policy and/or any homeowner’s insurance policy that may cover any of the losses Mr. Tom Smith is claiming against me. I have provided to Mr. Tom Smith, and his attorneys, copies of all insurance policies under which I could possibly be construed as an insured and that the only policy I have is the P. Insurance Company.
7. That I was not within the course and scope of my employment at the time of the collision on March 1, 2017.
8. That I have not transferred to any other person any assets over $1,000.00
within the last year.
9. That I do not own any assets worth $5,000.00 or more. I do not own any
stocks, bonds or real estate.
10. That my income consists entirely of _________17k (annual)__________________________________________ __________
My employers for the past two years are: __________________________________________________ _________________________.
11. That I understand Mr Tom Smith., and his attorneys are relying on all of my aforementioned representations made in this declaration.
12. That I understand that but for all of my aforementioned representations
made in this declaration, Mr. Tom Smith, and his attorneys would not accept the $_______ policy limits offer of settlement on my Insurance Policy with P. Insurance Company.
13. That should this matter proceed to litigation, the Superior Court of California would retain jurisdiction, even if the case is dismissed, to enforce the terms of this declaration under CCP Section 664.6 until performance in full of the terms of the settlement.
I declare under penalty of perjury that the above is true and correct. Executed at ________________________, California on _______________________.