Insurance No Claims Document

INSURANCE NO CLAIMS DOCUMENT

This Insurance No Claims Document is a sworn declaration by the insured that no claims, losses, or incidents giving rise to a claim were reported, paid, pending, or outstanding during the policy period specified below except as expressly listed in this document. False statements contained herein may result in denial of coverage, rescission of the policy, civil liability, or criminal penalties under applicable law.

Insured / Applicant Information

Policy Details

Policy Type: Auto Homeowners General Liability Professional Liability Other

Policy Period: From to

Coverage Items (check all that apply)

Bodily Injury / Liability
Property Damage
Collision
Comprehensive
Uninsured/Underinsured Motorist
Personal Injury Protection
Business Interruption
Professional Liability / E&O

Exclusions (Representative — read carefully)

The following categories are normally excluded unless expressly endorsed: intentional acts, fraud, nuclear hazards, war and insurrection, wear and tear/mantenace, losses arising from willful violation of law, liabilities assumed under contract not covered by the policy, punitive or exemplary damages where excluded by law or policy. This No Claims declaration does not expand coverage beyond policy terms, nor does it modify any exclusion, limitation or condition of the policy.

I acknowledge I have read and understand the exclusions and limitations described above and that this declaration is limited to the insured facts represented herein.

Claims Declaration

I declare that during the Policy Period specified above:

No claims, losses, incidents, or potential claims were reported, paid, reserved, or outstanding.

There are claims, losses, or incidents to report (if selected, provide full details below).

Documentation Checklist (if applicable)

Police report
Repair estimates
Photographs of damage
Witness statements
Other documentation

Beneficiary Information (if applicable)

Declaration and Certification

By signing below I certify that the statements and representations made in this Insurance No Claims Document are true and complete to the best of my knowledge. I authorize the insurer named above and its authorized agents to verify any information contained herein, to obtain and disclose information from prior insurers or other sources for the purpose of underwriting or rating, and to rely on this declaration in administering or renewing the policy. I understand that this declaration does not amend the policy and that coverage will be determined solely by reference to the policy documents. I understand that knowingly providing false or misleading information may subject me to civil and criminal penalties and may void coverage.

I further agree to promptly notify the insurer in writing of any claim, loss, occurrence, or change in circumstances that arises after the date of this declaration and before the effective date of any new or renewed coverage for which this declaration is submitted.

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