New Hampshire Code of Administrative Rules
Ins - Commissioner, Insurance Department
Chapter Ins 1400 - AUTOMOBILE INSURANCE
Appendix 1

Form INS 1 Statement of Residency Including Applicable Exemptions

(a) A resident is a person who maintains his or her true, fixed, and permanent residence within the state of New Hampshire, does not claim residency in any other state for any purpose, and who has, through all of his or her actions, demonstrated a current intent to designate that the permanent residence is his or her principal place of physical presence for the indefinite future to the exclusion of all others; or

(b) A resident is a person who is without a permanent street address due to homelessness or a person who is temporarily without a permanent street address due to traveling outside of the state of New Hampshire in a recreational vehicle for a period not to exceed 2 years and who has met and can demonstrate the requirements of RSA 261:52-b or RSA 261:52-c.

(c) Exemption from residency may be claimed if:

(1) The motor vehicle to be insured is garaged exclusively in New Hampshire; or

(2) The individual is on active duty in the military service of the United States and claims New Hampshire as their legal state of residence; or

(3) The individual is on active duty in the military service of the United States, currently stationed in New Hampshire, and all vehicles to be insured on this policy are currently garaged in New Hampshire.

(d) I understand that if I falsely claim for myself or any named insured to be a resident of the State of New Hampshire, or if I falsely claim for myself or any named insured to be entitled to exemption hereunder, I am subject to prosecution, imprisonment of up to one year, a fine of $2,000, and the denial of coverage for any loss, not occurring in New Hampshire, under the automobile insurance policy for which I am applying.

(e) I also understand that this statement will be relied upon in connection with future renewals of the automobile insurance policy for which I am applying, and that it is my responsibility to inform my insurance company before my next renewal after I or any named insured ceases to be a New Hampshire resident, and that I will be subject to the penalties listed in (d) above if I fail to do so.

(f) I/we, the applicant(s), has/have read the above and understand the penalties that may apply if I/we falsely claim to be a New Hampshire resident, or if I/we claim to be entitled to exemption hereunder.

CHECK ONE:

_____ I hereby attest that I am, and each named insured is, a resident of the State of New Hampshire as defined in (a) or (b) above and that I maintain a permanent residence located at (street address) in (city/town), New Hampshire, or that I, and each named insured, has met and can demonstrate the requirements of RSA 261:52-b or RSA 261:52-c as defined in (b) above..

_____ I hereby claim that I am, and each named insured is, entitled to exemption hereunder pursuant to (c) above.

Signed at (city/town), (county), (State), this (date) of (month), (year).

Date: Signature(s):