NO KNOWN OR REPORTED LOSS STATEMENT - INDIVIDUAL PROVIDERS

Sep 15, 2026

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NO KNOWN OR REPORTED LOSS STATEMENT - INDIVIDUAL PROVIDERS is a certification form for an authorized individual to declare that there are no known or reported claims, demands, suits, disciplinary or licensing proceedings, or investigations related to the referenced insurance policy. It requires identification details, a proposed effective date, and statements about the absence of incidents, injuries, adverse outcomes, or unresolved controversies that could trigger coverage. The form also includes signature, typed name, title, current date, and a fraud notice.

LanguageEnglish

CategoryLetters

FormatPDF

Pages1

AccessFree to download

Certification Information

Insured Authorization

No Known Loss Declarations

Exceptions and Signature

Fraud and Notice

NO KNOWN OR REPORTED LOSS STATEMENT – INDIVIDUAL PROVIDERS Legal Name: Mailing Address: Reference or Policy Number: Proposed Effective Date of Coverage: I hereby certify that I, (enter legal name), am authorized to make the following statements on behalf of myself and all others who may qualify as Insureds (an “Insured”) under the policy regarding claims, lawsuits, and events that could result in claims or lawsuits covered or potentially covered under the captioned policy. On behalf of myself and all others who may qualify as Insureds covered by the captioned policy, I hereby certify that from through , and with the exception of the claims and lawsuits (if any) listed below: • I am not aware of any claims, demands, suits, or disciplinary or licensing proceedings or investigations against myself or any proposed Insured; and • I am not aware of any circumstances, incidents, situations, accidents, complications, injuries or adverse outcomes , conditions or other unresolved controversies or other matters that might give rise to a claim under this policy or any renewals thereof; and • I understand that this Statement is used by Admiral Insurance Company as a basis for providing the insurance afforded by the captioned policy. I acknowledge that any contract of insurance issued by Admiral Insurance Company in response to this Statement will be in full reliance upon the representations made in this Statement. I am further aware that any inaccuracies or falsehoods concerning my assertion of “No Known Losses” are potentially grounds for denial of a specific claim, or cancellation or rescission of the policy of insurance. Except as follows: If “None", so state: Signature: Typed Name: Current Date: Title: Notice: Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance, or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any material fact, commits a fraudulent insurance act, which is a crime and may also be subject to civil penalty.

FAQs

Who must complete the NO KNOWN OR REPORTED LOSS STATEMENT for an individual provider?

The statement must be completed by the person whose legal name is entered and who is authorized to make the statements on their own behalf and on behalf of other qualifying Insureds under the referenced policy.

What types of claims or incidents does the form require the signer to declare as unknown?

The signer certifies they are not aware of any claims, demands, suits, disciplinary or licensing proceedings, investigations, or circumstances/incidents that could give rise to a claim under the policy or its renewals.

What happens if the signer’s “No Known Losses” representation is inaccurate or false?

The form states that inaccuracies or falsehoods may be grounds for denial of a specific claim and may also support cancellation or rescission of the insurance policy.

Sep 15, 2026

Upload by Aladdin