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Statement of No Loss

This document is a statement of no loss, certifying that the named insured is not aware of any losses, accidents, or circumstances that could result in an insurance claim under the specified policy number during the listed time period. The statement includes fields for the insured's signature and witness, agent information, and a receipt for any payment received.

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139 views1 page

Statement of No Loss

This document is a statement of no loss, certifying that the named insured is not aware of any losses, accidents, or circumstances that could result in an insurance claim under the specified policy number during the listed time period. The statement includes fields for the insured's signature and witness, agent information, and a receipt for any payment received.

Uploaded by

a v
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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STATEMENT OF NO LOSS

AGENCY NAMED INSURED

CONTACT CARRIER NAIC CODE


NAME:
PHONE
(A/C, No, Ext):
FAX POLICY NUMBER
(A/C, No):
E-MAIL
ADDRESS:
CODE: SUBCODE: APPROVED BY

AGENCY CUSTOMER ID:

I CERTIFY THAT I AM NOT AWARE OF ANY LOSSES, ACCIDENTS


OR CIRCUMSTANCES THAT MIGHT GIVE RISE TO A CLAIM UNDER
THE INSURANCE POLICY WHOSE NUMBER IS SHOWN ABOVE,
FROM 12:01 AM ON TO .
CANCELLATION DATE DATE AND TIME SIGNED

APPLICANT'S SIGNATURE

RECEIPT

$ AMOUNT RECEIVED BY:


PRODUCER

WITNESS DATE AND TIME

ACORD 37 (2008/01) © 1996-2008 ACORD CORPORATION. All rights reserved.


The ACORD name and logo are registered marks of ACORD
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