STATEMENT OF NO LOSS - declaration form

Sep 15, 2026

Uploaded by Asher

Statement of No Loss form for insurance underwriting and recordkeeping. Collects producer contact details, old and new policy numbers, insured information, and the approved underwriter. Includes a certification section stating there have been no losses, accidents, or circumstances that could lead to a claim under the policy referenced above. Provides fields for dates, coverage period, applicant signature and company name, receipt and notary public acknowledgment with seal and commission expiry.

LanguageEnglish

CategoryLetters

FormatPDF

Pages1

AccessFree to download

STATEMENT OF NO LOSS

Producer information

Policy and insured details

Certification of no loss

Signatures, receipt, and notary acknowledgment

FAQs

What information does the Statement of No Loss collect from the producer?

It records the producer’s name, address, and phone number, along with approval by the underwriter.

What does the certification section require the applicant to confirm?

The applicant certifies that there have been no losses, accidents, or circumstances that might give rise to a claim under the policy shown above.

What acknowledgment and signature steps are included?

The form includes the applicant’s signature and company name, a receipt received-by section, and a notary public area with seal and commission expiry.

Sep 15, 2026

Uploaded by Asher