Insurance No Loss GL Form

INSURANCE NO LOSS GENERAL LIABILITY (GL) FORM

Client Name:    Insured Name (if different):

Applicant / Insured Information

Policy Details

Insurance Company:    Policy Number:

Coverages (Check all that apply)

Bodily Injury
Property Damage
Products/Completed Operations
Personal & Advertising Injury
Medical Payments
Fire Legal Liability

Exclusions and Known Exceptions

Check if there are no known exclusions affecting the coverage described above: No known exclusions

No Loss Declaration

By signing below the undersigned hereby certifies that, during the policy period indicated above, there have been no occurrences, incidents, claims, suits, notices of circumstance, or demands made against the insured that would give rise to liability under the General Liability coverage afforded by the referenced policy, whether such matters arose from insured operations, products, premises, or completed operations.

The undersigned further certifies that no loss runs, claims histories, or other records held by the insured, its brokers, or representatives disclose any paid claims, open claims, or reserves attributable to the policy period stated above, except as disclosed in writing on this form.

Are there any incidents or potential claims that were reported to any insurer, broker or third party but did not result in a claim being opened?   Yes No

Documentation Checklist

Please indicate which documents accompany this declaration:

Current loss run (statement of claims history)
Incident reports (if any)
Current certificate of insurance
No documents attached

Beneficiary / Payee Designation (For Return Premium or Notices)

Name:    Relationship:

Payable Percentage:    Mailing / Remittance Address:

Certification and Authorization

I certify, under penalty of law, that the information provided herein is true, correct and complete to the best of my knowledge. I authorize the insurer and its representatives to verify any information contained in this form, to obtain loss history, and to rely upon this certification for underwriting, rating, renewal, or endorsement decisions. I acknowledge that intentional misrepresentation or omission of material facts may result in denial of coverage, rescission, or other remedies as permitted by law and policy terms.

I further understand that this No Loss Declaration does not alter, amend, or extend any policy terms, conditions, endorsements or exclusions unless reflected in a formal written endorsement issued by the insurer.

Sign Now