Who can sign the form?

An authorized officer of the insured or an authorized broker/agent may sign. Confirm carrier requirements for proof of authority; some carriers require a corporate resolution or broker authorization before accepting third-party signatures.

Can the form be e-signed?

Yes, electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided the platform captures intent, consent, attribution, and retention. Confirm carrier acceptance of e-signed declarations.

Is notarization required?

Not typically required for most No Losses Forms, but some carriers or state rules may request notarization or witness attestations. Verify carrier instructions and state-specific notary rules before submitting.

What if a prior loss is discovered later?

Notify the carrier promptly. Failure to disclose material losses can lead to premium adjustments, denial of claims, or policy rescission depending on the materiality and timing of the omission.

How long should I keep the signed form?

Retain the signed form for the policy term plus a minimum of three years; extend retention for tax, real estate, or healthcare-related records as required by applicable law or carrier policy.

What supporting documents help verification?

Attach the policy declarations page, loss runs, and any inspection reports or photos requested by the carrier to speed underwriting review and reduce follow-up requests.

Electronic Signature
Templates
Insurance
Insurance No Losses Form

Insurance No Losses Form

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

INSURANCE NO LOSSES FORM

Insured Name: Policy Number:

Insurer Name: Policy Period: From to

Applicant / Insured Information

Mailing Address Date of Birth Contact Phone Email Address

Policy Details

Policy Type Coverage Amount Deductible Annual Premium

Coverage Applicable

General Liability Property Auto

Workers' Compensation Professional Liability Other:

Certification of No Losses

Reporting Period: From to

I certify that, to the best of my knowledge and belief, no claims, losses, incidents, occurrences, suits, demands, or notices of potential claim arising from the operations or exposures insured under the above policy were sustained, reported, or are known to exist during the reporting period identified above.

By checking this box and signing below, I affirm the foregoing statement is true and complete. I acknowledge that any material misrepresentation or omission may be grounds for denial of coverage, rescission, or other remedies permitted by law and policy terms.

If any loss or incident occurred, provide date(s) and description

Supporting documentation attached: Yes

Exclusions / Known Restrictions

Known Exclusions, Endorsements, or Restrictions

Beneficiary Information

Beneficiary Name Relationship to Insured Allocation Percentage

Declaration and Certification

I certify under penalty of perjury that the information provided herein is true, correct and complete to the best of my knowledge. I understand that this certification is provided for the purpose of underwriting, renewal, or issuance of insurance coverage and that the insurer may rely upon these statements in evaluating the risk. I further authorize the insurer to make any inquiries and to obtain any records or information necessary to verify the statements made in this form.

I understand that intentional misrepresentation, false statements, or omission of material facts may constitute insurance fraud and may subject me to civil or criminal penalties as permitted by law and the terms of the policy.

Insured Printed Name:

Signature:

Date:

What the Insurance No Losses Form Is and when it matters

The Insurance No Losses Form is a written statement provided to an insurer or third party confirming that the named policyholder or insured has had no reportable claims, losses, or incidents during a specified prior period. It is commonly used in commercial and personal lines underwriting, policy renewal negotiations, and premium audits to verify a clean claims history. Carriers and agents rely on the form for pricing, risk classification, and eligibility for certain discounts or coverage endorsements. The statement is factual and typically signed by an authorized representative of the insured entity.

Why an accurate No Losses statement matters

A correct Insurance No Losses Form reduces underwriting friction, supports accurate premium calculation, and establishes a clear record for renewals and audits. It protects both the insured and insurer by documenting the absence of claims during the stated period.

Who typically completes and relies on this form

The Insurance No Losses Form is used by insurers, brokers, agents, risk managers, and insured parties during underwriting, renewal, or coverage change processes.

Insurance agents and brokers who collect verified histories from clients before submitting renewal paperwork to carriers.
Corporate risk and compliance officers certifying loss-free periods to obtain preferred pricing or endorsement eligibility.
Individual policyholders confirming no auto or property claims for discount qualification or new-policy issuance.

Accurate completion and an auditable signature help avoid disputes, support premium adjustments, and speed processing by underwriters.

Step-by-step: Filling and submitting the Insurance No Losses Form

Follow these core steps to complete the form accurately and reduce processing delays.

01

Gather policy details: Locate policy number, coverage type, and current declarations page.
02

Confirm reporting period: Verify exact start/end dates for the period you are certifying.
03

Complete declaration fields: Enter name, policy number, coverage line, and check the no-loss box.
04

Sign and date: Have an authorized signer sign with date and contact information for verification.

Typical process flow after you submit the form

Underwriters and administrators use a short verification workflow before updating policy records.

Receipt: Carrier or broker logs the submission into the policy system.
Verification: Underwriting checks declarations page and claims history for confirmation.
Update: Policy record updated for premium or endorsement adjustments if applicable.
Archive: Signed form stored with the policy file for audit and retention purposes.

How to configure a digital workflow for No Losses statements

Set fields and routing so the right person signs and the insurer receives an auditable record.

Field	Configuration
Policy Number Field	Required, single-line text
Date Range Field	Two date fields (MM/DD/YYYY)
Signature Field	Signer required; attach signer name/title
Routing	Send to broker then underwriter

Sharing and eSubmission options for the Insurance No Losses Form

Forms can be shared by email, secure upload, or via an eSignature platform that preserves an audit trail.

Email: Send PDF with signature request; ensure secure transmission for PHI.
Integrations: Use integrations with CRMs or policy systems (Salesforce, NetSuite) to auto-link submissions.
eSignature Platform: Choose a platform that captures timestamps, IP, and signer authentication.

Preserve the signed copy in the policy file and ensure the carrier accepts the chosen submission method to avoid processing delays.

Typical timelines and processing expectations

Processing time varies by carrier and whether additional verification is required.

Immediate Acknowledgement:

Carrier/broker often acknowledges receipt within 1–3 business days.

Underwriting Review:

Underwriter verification commonly completed within 3–10 business days.

Policy Update:

Policy changes or premium adjustments posted within 7–30 days after approval.

Request for Clarification:

If discrepancies appear, expect follow-up within 5–10 business days.

Expedited Requests:

Use broker escalation for urgent renewals; timing depends on carrier SLA.

Key milestones from submission to policy update

A typical milestone sequence helps set expectations for each stage of review and record updates.

01

Submit Form

Signed form delivered to broker or carrier; begins the review clock.

02

Receipting

Carrier logs and acknowledges submission within business days.

03

Verification

Claims and policy checks validate the no-loss declaration.

04

Finalize Update

Underwriter approves and posts any premium or endorsement changes to policy.

Common mistakes to avoid when preparing the form

Using an unauthorized signer or failing to include a title can invalidate the declaration.
Entering incorrect policy numbers or dates that do not match the declarations page delays verification.
Adding ambiguous language or qualifiers in the no-loss statement that prompt carrier follow-up.
Failing to include contact information for the signer prevents quick carrier verification.

Risks and consequences of inaccurate No Losses statements

Coverage denial: Insurer may deny specific claims if misrepresentation of loss history is discovered.

Policy rescission: Intentional or material misstatement can lead to rescission of policy.

Premium adjustment: Underwriter may retroactively adjust premiums if a prior loss is omitted.

Contractual penalties: Some policies include contractual remedies for misrepresentation.

Regulatory exposure: False statements to insurers can trigger state insurance department inquiries.

Reputational risk: Repeated inaccuracies can harm broker-carrier relationships.

How the Insurance No Losses Form differs from similar documents

Compare the No Losses Form to related documents so you use the correct instrument for each purpose.

Document Type	Purpose	When to use
Loss History Report	detailed claims list	use for underwriting deeper review
Declaration Page	policy terms summary	use to verify coverage and policy number
Claims Authorization	release for records	use to permit carrier access to third-party records
Broker Statement	agent summary	use for internal carrier correspondence

Typical eSignature vendor pricing and capability snapshot for submitting No Losses Forms

Platform selection affects cost, bulk sending, audit trails, and HIPAA readiness; signNow is shown first per comparison conventions.

	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
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No envelope cap	100 envelopes/user/year	Varies	Varies	Varies

Real-world scenarios where a No Losses Form is used

Two practical examples show how the form fits common workflows.

Broker Renewal Submission

A broker collects a signed no-loss declaration from a small business client to support a renewal quote

The broker attaches the declarations page and recent loss runs
The carrier completes verification and issues a renewal with a reduced premium based on the verified clean history, all logged in the policy system for audit.

Corporate Risk Certification

A risk manager certifies no auto liability claims for the prior 12 months to qualify for a fleet discount

The insurer requests contact info for verification
After confirmation, the insurer applies the fleet discount and archives the signed form with the corporate policy file.

Who may be authorized to sign the Insurance No Losses Form

Chief Risk Officer

A senior officer with explicit delegated authority may sign on behalf of the organization; carriers typically accept signatures from C-suite or designated risk managers when authority is documented in corporate resolution or binder.

Licensed Agent / Broker

An insurance producer or broker with client authorization can sign and submit the form for the insured, provided carrier procedures allow third-party submissions and an authorization letter or broker of record letter is on file.

Frequently asked questions about the Insurance No Losses Form

Answers to common procedural and legal questions to help avoid delays or rejections.

Need help? Contact support

Who can sign the form?
An authorized officer of the insured or an authorized broker/agent may sign. Confirm carrier requirements for proof of authority; some carriers require a corporate resolution or broker authorization before accepting third-party signatures.
Can the form be e-signed?
Yes, electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided the platform captures intent, consent, attribution, and retention. Confirm carrier acceptance of e-signed declarations.
Is notarization required?
Not typically required for most No Losses Forms, but some carriers or state rules may request notarization or witness attestations. Verify carrier instructions and state-specific notary rules before submitting.
What if a prior loss is discovered later?
Notify the carrier promptly. Failure to disclose material losses can lead to premium adjustments, denial of claims, or policy rescission depending on the materiality and timing of the omission.
How long should I keep the signed form?
Retain the signed form for the policy term plus a minimum of three years; extend retention for tax, real estate, or healthcare-related records as required by applicable law or carrier policy.
What supporting documents help verification?
Attach the policy declarations page, loss runs, and any inspection reports or photos requested by the carrier to speed underwriting review and reduce follow-up requests.

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