Can this statement be signed electronically?

Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted. Ensure intent, consent, attribution, and reproducible record retention to meet the ESIGN four‑prong test.

Do insurers require notarization or witnesses?

Requirements vary by insurer and jurisdiction. Some carriers ask for notarization or witnessed signatures for higher‑risk accounts; check policy conditions and state notary rules before submission.

What happens if a previously unknown loss is discovered?

Promptly notify the insurer. Late disclosure can lead to underwriting adjustments, claim denial, or rescission depending on policy language and materiality of the omission.

Who is authorized to sign for a corporation?

A corporate officer or an authorized representative listed in corporate records should sign. Insurers may request a corporate resolution or authority letter if signer authority is unclear.

Are Remote Online Notarizations (RON) acceptable?

RON acceptance depends on state law and carrier policy. Many states permit RON; confirm state RON rules and insurer acceptance before using a remote notarization service.

How long should I retain a signed statement?

Keep signed statements for at least the policy term plus applicable retention periods (IRS 3 years, HIPAA 6 years when applicable) and longer if litigation or claim activity exists.

Electronic Signature
Templates
Insurance
Insurance No Known Loss Statement

Insurance No Known Loss Statement

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Insurance No Known Loss Statement

Applicant / Insured Information

Applicant / Insured Name

Date of Birth

Telephone

Residence / Mailing Address Email Address

Policy Details

Insurer / Company Name

Policy Number

Policy Type (select all that apply)

Property
Liability
Auto
Inland Marine
Flood
Crime
Other:

Coverage Limit (per occurrence)

Deductible

Policy Period - From

Policy Period - To

Statement of No Known Loss

I, , being the applicant/insured identified above, hereby certify that as of the date of this statement there are no known incidents, losses, claims, occurrences, facts, or circumstances that could reasonably give rise to a claim under the policy identified above or any renewal, endorsement, or new policy for which coverage is sought.

This statement applies to the period beginning and ending , including but not limited to events that would otherwise be reportable under any prior or current policy.

Affirmation I affirm that there are no known losses, claims, incidents, or circumstances to disclose for the period identified above.

Known Loss Disclosure (if applicable)

If you have any knowledge of a loss, claim or circumstance that might give rise to a claim, check the box below and provide a full description. Failure to disclose material facts may result in denial of coverage or rescission. I have knowledge of one or more incidents/losses to disclose Description of Loss / Circumstance

Date of Loss

Estimated Amount of Damage

Claim Reported to Insurer? Yes No Claim Reference / File Number (if reported)

Exclusions & Acknowledgment

I understand and acknowledge that this statement does not amend, extend, or alter any existing policy terms, conditions, exclusions, or limits. I further acknowledge that material misrepresentation, omission, or fraudulent statements may permit the insurer to deny coverage, rescind the policy, or pursue other remedies available under applicable law.

I acknowledge receipt of and understand the exclusions described above and represented in this statement.

Beneficiary Information (if applicable)

Provide beneficiary details where applicable to the policy type identified above. Allocate whole percentages; total should equal 100% where required by policy.

Beneficiary 1 - Name

Relationship

Share %

Beneficiary 2 - Name

Relationship

Share %

Beneficiary 3 - Name

Relationship

Share %

Certification and Authorization

By signing below I certify that the foregoing statements are true, complete and correct to the best of my knowledge. I understand that this statement is a material representation relied upon by the insurer in determining whether to issue, renew, or modify insurance coverage. I acknowledge that any material misrepresentation or omission may result in denial of coverage, rescission of any policy issued, or other legal remedies available to the insurer. I authorize the insurer and its representatives to make any inquiries necessary to verify the information provided herein, including inquiries to third parties or consumer reporting agencies where permitted by law.

I further understand that this statement is limited to the matters expressly set forth herein and does not constitute a waiver or modification of policy terms, conditions, or exclusions unless expressly agreed to in writing by an authorized representative of the insurer.

Printed Name:

Signature:

Date:

What an Insurance No Known Loss Statement Is

An Insurance No Known Loss Statement is a written attestation used by applicants, insureds, or agents to confirm that, to the signer’s knowledge, no reportable losses, claims, or incidents have occurred within a specified prior period. Insurers and brokers use the statement during underwriting, certificate issuance, or policy changes to verify loss history and evaluate risk. The statement typically identifies the named insured, policy or application details, the lookback period, and a signed declaration under penalty of false statement or fraud.

Why the Statement Matters to Underwriting and Coverage

A clear No Known Loss Statement reduces underwriting ambiguity, speeds policy issuance, and creates a contemporaneous record that insurers rely on when quoting or extending coverage.

Who Typically Completes or Requests This Statement

Roles vary by transaction; often both the insured and broker retain copies for proof of disclosure.

Insurance brokers and agents who collect attestations from applicants prior to binding coverage or issuing certificates of insurance.
Named insureds or corporate officers who must confirm absence of reportable losses for underwriting or endorsement requests.
Underwriters and risk managers who need a current attestation to price risk and determine policy terms.

Security and Compliance Considerations

Transport Encryption: TLS 1.2/1.3 in transit

Data at Rest: AES-256 encrypted storage

Audit Trail: Timestamps and IP logging

Regulatory Compliance: ESIGN and UETA compliant

Healthcare Support: HIPAA available with BAA

Certifications: SOC 2 Type II, ISO 27001

Penalties and Risks of Incorrect Statements

Coverage Rescission: Insurer may void coverage

Claim Denial: Claims tied to undisclosed losses denied

Fraud Exposure: Potential civil or criminal liability

Contractual Breach: Indemnity or penalty triggers

Underwriting Adjustment: Higher premiums or exclusions

Regulatory Scrutiny: State regulator inquiry possible

Common Pitfalls to Avoid

Using inconsistent legal names or abbreviations across the statement and policy leads to verification delays and possible requests for corrected documents.
Leaving the lookback period unspecified or ambiguous creates disputes about which incidents should be reported and may invalidate the attestation.
Failing to obtain an authorized signer’s signature or providing an unsigned form will prompt insurers to refuse reliance or request re-execution.
Submitting a no-known-loss attestation when relevant losses exist can lead to rescission, claim denial, or allegations of material misrepresentation.

How to Complete an Insurance No Known Loss Statement

Follow these straightforward steps to prepare and submit an accurate attestation.

01

Gather records: Collect policies, prior loss runs, and claims history
02

Fill fields: Enter insured name, policy number, and lookback period
03

Sign and date: Authorized signer signs in ink or electronically
04

Send to insurer: Deliver to broker or underwriting contact with certificate

Typical Submission Flow for the Statement

A standard e-submission workflow shortens processing and creates a verifiable record.

Prepare document: Populate fields and attach supporting loss runs
Apply signature: Signer authenticates and signs electronically
Send to underwriter: Email or platform delivery to insurer or broker
Receive confirmation: Insurer acknowledges receipt and stores record

Recommended Digital Workflow Settings

Configure your e-sign and storage settings to preserve evidentiary value and access control.

Field	Configuration
Authentication	Email link or SMS OTP for signer verification
Storage	Encrypted storage with AES-256 at rest
Notifications	Automated email on completion and download
Retention	Preserve signed record for regulatory period

Technical Compatibility and Integrations

Use integrations to streamline routing, archival, and insurer access while preserving an audit trail.

Supported formats: PDF and DOCX supported
Integrations: Salesforce, NetSuite, Microsoft 365
Auth options: Email, SMS OTP, SSO

Typical Timing and Processing Expectations

Timing depends on the insurer’s underwriting cycle and whether additional documentation is requested.

Pre-coverage:

Provide prior to policy effective date

Renewal requests:

Submit with renewal paperwork, often 30–60 days prior

Insurer review:

Underwriting response often within 5–15 business days

Supplemental info:

Respond promptly to requests to avoid delays

Record retention:

Retain signed copies according to regulatory rules

Core Elements of a Professional No Known Loss Statement

A complete statement includes specific data points and clear attestation language to ensure enforceability and insurer reliance.

Attestation Clause

A clear declaration that no known losses exist for the specified lookback period, drafted to avoid ambiguity and to state consequences for false statements.

Named Insured

Full legal name and DBA information where applicable, matching the policy or application to prevent identity mismatches during underwriting.

Policy Details

Policy number, insurer name, and coverage lines so the attestation is tied precisely to the relevant insurance instrument and period.

Lookback Period

Start and end dates for the period covered by the attestation; explicit dates prevent disputes about which incidents require disclosure.

Signature Block

Authorized signer’s printed name, title, signature, and date; include company seal or notarization if the insurer requires it.

Supporting Info

Optional attachments such as loss runs, claim summaries, or prior policy declarations to provide corroborating context for the attestation.

How This Statement Differs from Common Insurance Documents

Compare the No Known Loss Statement with related documents to select the correct form for your purpose.

Criteria	Insurance No Known Loss Statement	Certificate of Insurance
Purpose	attestation of no claims	proof of current coverage
Typical sender	insured or agent	insurer or agent
Signed?	yes, by authorized representative	issued by insurer signature
When used	underwriting and attestations	verification for third parties

eSignature Vendor Comparison for Executing This Statement

Cost, bulk-send, audit trail, and HIPAA support matter when choosing an eSignature provider for insurance attestations.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
Envelope Cap	No cap	100 envelopes/user/year	Varies	Varies	Varies

Practical Use Cases

Real-world examples show how the statement is used across common transactions.

Commercial Lease Addendum

A tenant provides a No Known Loss Statement to the landlord when adding an additional insured

The statement confirms no prior property damage claims during the lookback period
The landlord accepts the attestation and the insurer updates the certificate to add the landlord as additional insured, streamlining occupancy approval.

Contractor Prequalification

A general contractor submits the statement with bid documents to a project owner

It attests to no open liability claims during the prior 36 months
The owner uses the attestation alongside loss runs and certificates to evaluate contractor risk and award the contract.

Key Milestones from Request to Record

Track milestones to ensure timely underwriting and maintain an auditable timeline.

01

Request Received

Broker or insurer requests attestation from insured

02

Insured Response

Insured prepares and signs the statement

03

Underwriter Review

Insurer reviews and requests clarifications if needed

04

Record Retention

Store signed record per retention policy

FAQs: Common Questions About the Statement

Answers to frequent practical and legal questions about completing and relying on a No Known Loss Statement.

Need help? Contact support

Can this statement be signed electronically?
Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted. Ensure intent, consent, attribution, and reproducible record retention to meet the ESIGN four‑prong test.
Do insurers require notarization or witnesses?
Requirements vary by insurer and jurisdiction. Some carriers ask for notarization or witnessed signatures for higher‑risk accounts; check policy conditions and state notary rules before submission.
What happens if a previously unknown loss is discovered?
Promptly notify the insurer. Late disclosure can lead to underwriting adjustments, claim denial, or rescission depending on policy language and materiality of the omission.
Who is authorized to sign for a corporation?
A corporate officer or an authorized representative listed in corporate records should sign. Insurers may request a corporate resolution or authority letter if signer authority is unclear.
Are Remote Online Notarizations (RON) acceptable?
RON acceptance depends on state law and carrier policy. Many states permit RON; confirm state RON rules and insurer acceptance before using a remote notarization service.
How long should I retain a signed statement?
Keep signed statements for at least the policy term plus applicable retention periods (IRS 3 years, HIPAA 6 years when applicable) and longer if litigation or claim activity exists.

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