State of No Loss

Statement of No Loss

When a policy has lapsed and is being reinstated, the carrier requires written confirmation that no losses have occurred during the lapse period. Complete and sign below.

Policyholder

First name *

Last name *

Email *

Phone *

Policy

Insurance carrier

Policy number *

Cancellation / expiration date *

Today's date *

Ending time today The time you are signing this today.

Declaration I certify that no accidents, losses, claims, or circumstances that could result in a claim have occurred during the lapse period stated above, and none are known or pending as of the date signed below.

If any losses did occur, describe them here (leave blank if none)

Type your full legal name *

Date *

Signature *

Sign above using your mouse or finger.