Insurance No Loss Certificate

INSURANCE NO LOSS CERTIFICATE

Certificate Issued To: Insured Name:    Policy Number:

Applicant / Insured Information

Policy Details

Policy Period: From to

Coverage Sections (select applicable coverages)

General Liability Property Auto

Professional Liability Workers' Compensation Other (specify below)

No-Loss Declaration

The undersigned, being an authorized representative of the insured, hereby certifies that during the policy period set forth above no occurrences, incidents, claims, suits, demands, notices of circumstances, potential claims, or events that could reasonably give rise to a claim under the identified policy have been made against the insured nor have any such matters been reported to any insurer, except as fully described in the space below.

Number of claims or potential claims during the policy period:

Documentation attached (check all that apply): Police report Repair/repair estimates Photographs

Exclusions & Reservation of Rights

This certificate is a statement of fact by the insured only. It does not amend, extend, or alter the terms, conditions, exclusions, endorsements, or limits of the policy referenced above. The insurer reserves all rights to investigate, accept or deny coverage, to apply policy exclusions, to adjust premiums, and to rescind or otherwise modify coverage consistent with the policy and applicable law.

By checking the box below the undersigned acknowledges that exclusions in the underlying policy (including but not limited to intentional acts, pollution, war and contractual liability) remain applicable and that this certificate does not expand coverage beyond the policy terms. Acknowledged

Beneficiary Information

Primary Beneficiary Name:

Relationship:    Share (%):

Certification and Authorization

The undersigned declares under penalty of civil and criminal liability for willfully false statements that the information provided herein is true and complete to the best of the undersigned's knowledge. The undersigned further warrants that they are authorized to make this certification on behalf of the insured. The insurer, its authorized representatives, and any contracted third parties are authorized to make such inquiries and to obtain such records as reasonably necessary to verify the statements made in this certificate.

The undersigned understands that any material misstatement or omission in this certificate may entitle the insurer to deny coverage, adjust premiums, rescind the policy, or pursue other remedies allowed by the policy or law.

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