Insurance No Known Losses Form

INSURANCE NO KNOWN LOSSES FORM

Use this form to provide a formal declaration that, as of the date indicated below, the insured has no known losses, claims, incidents, potential claims, or circumstances that could reasonably be expected to give rise to a claim under the policy(ies) identified herein. Complete all fields, sign and date the certification. False statements may be subject to denial of coverage and may have civil or criminal consequences.

Applicant / Insured Information

Individual    Corporation    LLC    Partnership    Other

Policy Details

Policy Period: From to

Coverage Types (check all that apply)

General Liability    Property / Commercial Property    Automobile / Fleet    Professional Liability / E&O
Workers' Compensation    Cyber Liability    Umbrella / Excess

Statement of No Known Losses

As of , the undersigned certifies the following under penalty of law:

1. The insured has no known losses, claims made, incidents reported, or circumstances that could reasonably be expected to give rise to a claim under the policy(ies) identified above:
I certify NO KNOWN LOSSES OR POTENTIAL CLAIMS EXIST

2. There are no pending notices of claim, lawsuits, administrative proceedings, or demands that relate to the exposures covered by the policy(ies):
I certify NO PENDING ACTIONS OR DEMANDS

Material Change / Reporting Obligation

The insured warrants that no material change in the risk described in the policy(ies) has occurred since the policy inception date, other than as disclosed in writing to the insurer. The insured agrees to promptly notify the insurer in writing of any event, circumstance, claim, potential claim, or other matter that arises after the date of this certification which could reasonably give rise to a claim under the policy(ies).

Exclusions / Limitations

This declaration does not change, amend, or waive any term, condition, exclusion or limitation of the policy(ies). The insurer retains all rights to investigate any reported matter and to apply policy provisions, including coverage defenses, exclusions, and limits, as permitted by law and contract.

Beneficiary / Payee Information (if applicable)

Primary Beneficiary Name:    Relationship:    Percentage:

Contingent Beneficiary Name:    Relationship:    Percentage:

Certification and Authorization

I, the undersigned, certify that I am authorized to make this declaration on behalf of the insured identified above. I represent that the statements made herein are true and complete to the best of my knowledge and belief. I understand that this certification is a material representation upon which the insurer may rely in determining rights and obligations under the policy(ies). I further acknowledge that failure to disclose known losses or circumstances may result in denial of coverage, rescission of the policy, premium adjustments, or other remedies available under law or contract.

I authorize the insurer, its representatives and agents to make any inquiries necessary to verify the statements contained in this form, including but not limited to claims history inquiries, and I agree to cooperate in any investigation of matters reported or discovered.

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