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underwriting@securitymutual.com)[underwriting@securitymutual.com](Email: underwriting@securitymutual.com)[ ](Email: underwriting@securitymutual.com)[www.securitymutual.com](www.securitymutual.com)  \nSTATEMENT OF NO LOSS  \nPolicy Number:    \nI certify that there have been no losses, accidents or circumstances that might give rise to a claim, under the insurance policy whose number is shown above.  \nFrom 12:01 am on   to   How is the home occupied?    \nAny 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 fact material hereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.  \nAuthorized Signature Date & Time  \nPrinted Name and description of authority  \nRECEIPT  \n$   Amount Received by:    \nWitness Date & Time  \nSeptember 2023","cbCaig8XrwZowFuY","https://ap.wps.com/l/cbCaig8XrwZowFuY","pdf",107920,"English","# Statement of No Loss\n## Certification Details\n## Fraud Warning and Legal Notice\n## Authorization and Receipt","[{\"question\":\"What is the purpose of the Statement of No Loss?\",\"answer\":\"The purpose of this form is to certify that no losses, accidents, or circumstances that could lead to an insurance claim have occurred under a specific policy during a defined period.\"},{\"question\":\"What information must the policyholder provide on this form?\",\"answer\":\"The policyholder must provide the policy number, the specific time frame covered by the statement, details on how the home is occupied, and an authorized signature with their printed name and authority description.\"},{\"question\":\"What are the consequences of providing false information on this document?\",\"answer\":\"Providing knowingly false or misleading information to an insurance company constitutes a fraudulent insurance act, which is a crime punishable by civil penalties of up to five thousand dollars plus the value of the claim.\"}]","Statement of No Loss - Insurance Policy Form | PDF",1789628242]