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Insurance No Losses Statement

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INSURANCE NO LOSSES STATEMENT

Applicant / Insured Information

Policy Details

Coverage Sections (select all that apply)

Property    Liability    Automobile / Motor    Professional Liability / E&O    Workers' Compensation    Other:

Statement of No Losses

I, the undersigned insured or authorized representative, hereby declare that for the policy identified above I have not sustained, reported, or had any claim, suit, demand, loss, event, occurrence, or accident that could give rise to a claim under the above policy during the period from to .

This statement includes, but is not limited to, any incidents that would give rise to property damage, bodily injury, professional liability, automobile damage or loss, workers' compensation claims, or any other contingent liability under the policy. No notices of circumstantial incidents, potential claims, or reserves have been made to any insurer, third party, or claimant in relation to the period stated above.

Exclusions and Acknowledgements

I acknowledge that this declaration is limited to the coverages listed and is subject to the terms, conditions, exclusions and limitations of the applicable insurance policy. This statement does not amend, extend, or waive any policy term or condition. I understand that the insurer reserves the right to investigate and verify the truthfulness and completeness of this statement and to obtain additional information where permitted by law.

I further understand that any material misrepresentation, omission, or fraudulent statement in this declaration may result in denial of coverage, rescission of the policy, adjustment of premium, or other remedies allowed by law and by the policy.

Beneficiary / Additional Interested Parties

Provide the name and relationship of any beneficiary or additional interested party that should be noted for the policy. If none, enter "None".

Supporting Documentation

Check any documents attached or indicate none. Attachments may be retained by the insurer for verification where permitted.

None    Photographs    Police / Incident Reports    Repair Estimates    Correspondence / Notices

Declaration and Certification

By signing below I certify, under penalty of applicable law and subject to the terms of the policy, that the information provided in this Insurance No Losses Statement is true, complete, and accurate to the best of my knowledge. I further certify that I am authorized to make this statement on behalf of the insured named herein. I acknowledge that the insurer may rely on this statement in determining coverage, eligibility for rate adjustments, or issuance of endorsements.

I authorize the insurer and its representatives to make inquiries and obtain records as necessary to verify the statements made herein and to investigate any matter related to this declaration. I understand that any material misrepresentation or omission may result in rescission of the policy, denial of claims, and other remedies permitted by law and by contract.

Applicant Name:

By:

Date:

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What the Insurance No Losses Statement Is

An Insurance No Losses Statement is a signed declaration by a policyholder or insured party confirming that no covered losses, claims, or incidents occurred during a specified period. Insurers commonly request this statement when renewing coverage, reinstating a policy, or issuing certain premium credits. The document documents the absence of claims exposure for the stated period and may be attached to underwriting files, audits, or regulatory records. Where required, the statement may be notarized or executed under penalty of perjury depending on the insurer's procedures and applicable state rules.

Why insurers and policyholders rely on this statement

The Insurance No Losses Statement provides a concise, auditable record that no claims occurred in the declared period, simplifying renewals and underwriting reviews while reducing follow-up inquiries between carrier and insured.

Why insurers and policyholders rely on this statement

Who typically completes or requests this statement

Typical users include agents, brokers, risk managers, and individual policyholders who must certify loss history for an insurer or reinsurer.

  • Independent Agents and Brokers confirm client loss history during renewal or placement.
  • Risk Managers verify portfolio-level exposures and support loss-control reporting.
  • Individual Policyholders sign to meet insurer renewal or premium-adjustment requirements.

The statement serves both internal underwriting teams and external parties such as auditors or lending institutions that require evidence of claims history.

Key signers and roles

Claims Manager

A claims manager signs on behalf of an insured entity after reviewing internal loss logs and verifying that no covered incidents occurred in the stated period. They document the review steps and attach supporting records to the insurer file for auditability.

Authorized Representative

An authorized representative (owner, officer, or designated agent) signs to attest to the organization's loss history. The signer must have authority to bind the organization and confirm accuracy under potential civil or criminal penalties for false statements.

Core components of an effective Insurance No Losses Statement

A professional statement combines clear identification, a precise period, a declarative no-loss assertion, signer authority, signature/date, and any required notarization to support insurer acceptance.

Insured Identity

Full legal name of policyholder and policy number to tie the statement to the correct account and policy period.

Coverage Period

Exact start and end dates for the period being certified; avoid ambiguous phrasing such as 'last year' or 'recently'.

No Loss Declaration

A plain-language sentence stating that no covered losses, claims, or incidents occurred within the stated dates.

Signer Authorization

A line identifying the signer’s title or capacity (owner, officer, broker) establishing authority to attest on behalf of the insured.

Signature and Date

Handwritten or electronic signature plus the execution date; include place of signing when required by insurer or state law.

Notary or Attestation

Notarization, witness blocks, or a sworn statement when requested by the carrier to increase evidentiary weight.

Essential data fields to include

Policyholder Name: Exact legal name
Policy Number: Carrier-assigned identifier
Period Covered: MM/DD/YYYY–MM/DD/YYYY
Statement Date: MM/DD/YYYY
Signer Title: Capacity or role
Signature: Handwritten or e-sign

Step-by-step: complete and deliver the statement

Follow these sequential steps to prepare a complete, auditable No Losses Statement for insurers or reinsurers.

  • 01
    Gather Documents: Collect policy details and loss run reports.
  • 02
    Fill Fields: Complete all required fields accurately.
  • 03
    Sign and Authenticate: Sign in authorized capacity; notarize if required.
  • 04
    Send to Carrier: Submit via insurer portal, email, or eSignature link.

Configuring an online workflow for this statement

Design a repeatable template and route that minimizes manual steps and preserves an audit trail.

Field Configuration
Template Name Standardized 'No Losses Statement' template for reuse
Required Fields Policyholder, policy number, period, signature, date
Authentication Email link + optional SMS or KBA for higher assurance
Retention Store signed PDF with audit trail for regulatory retention

Typical routing and submission flow

A standard submission flow clarifies responsibilities and creates an auditable chain from signer to carrier.

  • Prepare Template: Create a fillable PDF or form
  • Assign Signer: Add signer email and authentication level
  • Sign and Certify: Signer completes fields and signs
  • Deliver and Archive: Send to insurer and store with audit log

Digital signing and technical considerations

Ensure the chosen platform supports audit trails, required authentication, and export to standard PDF/A formats for long-term storage.

  • File Formats: PDF, DOCX supported
  • Integrations: CRM and storage connectors
  • Authentication: Email, SMS, KBA, or SSO

Verify the provider’s compliance certifications (ESIGN and UETA support, HIPAA BAA where needed, and AES-256 at rest/TLS in transit) before eSubmission.

Typical timing and response expectations

Timing varies by insurer and context; the following are common expectations to plan around.

On Request:

Provide statement promptly when carrier asks

Renewal Window:

Usually requested as part of 30–60 day renewal package

Underwriting Review:

Carrier may allow 7–14 days for verification

Notarization Lead Time:

Allow extra days if in-person notary is needed

Record Availability:

Keep signed copy accessible for audits (see retention)

Key milestones from request to archive

A sequential milestone list helps track progress and ensure deadlines are met.

01

Request Received

Carrier issues request for the no-loss certification

02

Preparation Complete

Loss runs and policy details reviewed

03

Execution

Signer completes signature and notarization if required

04

Submission and Archival

Statement delivered to carrier and stored with audit trail

Common mistakes to avoid

  • Using informal language or ambiguous dates that make verification difficult and trigger follow-up.
  • Mismatched names or policy numbers that lead to delayed underwriting or misfiled records.
  • Signing without authority or missing signer title, which may invalidate the attestation.
  • Failing to notarize when the insurer explicitly requires notarization or a sworn statement.

Consequences of inaccurate or false statements

Coverage Denial: Carrier may deny future claims
Policy Cancellation: Contract can be rescinded
Civil Liability: Insured may face breach claims
Criminal Risk: False sworn statements may trigger perjury charges
Premium Adjustments: Underwriting corrections can raise premiums
Audit Findings: Regulatory or reinsurer dispute exposure

Practical examples of how organizations use the statement

Two concise scenarios show common uses: renewal underwriting and lender verification during a financing event.

Renewal Submission

An insurer requests a no-loss statement for the prior 12 months

  • Broker obtains loss runs and completes the form
  • The signed, notarized statement is filed with the renewal packet and stored in underwriting records for auditability.

Lender Requirement

A bank requests evidence of no property liability claims before loan closing

  • Borrower provides the signed statement and supporting loss history
  • Lender accepts the document with the insurer’s acknowledgement and closes the loan.

Practical tips for accurate and efficient completion

Apply these practices to reduce rework and ensure insurer acceptance.

Standardize Template Wording
Use insurer-provided wording when available and standardize a single template for all renewals. Clear, consistent language reduces underwriting questions and speeds processing; include an internal checklist verifying policy number, period, signer authority, and attached loss runs before sending.
Confirm Signer Authority
Validate the signer’s capacity in advance. Maintain a roster of authorized signers and documented delegation to avoid invalid executions and re-sign requests that delay renewals or closings.
Use Electronic Signatures with Audit Trail
Adopt an eSignature workflow that records timestamps, IP addresses, and authentication methods. The audit trail strengthens acceptance and reduces reliance on manual notarization when carrier policies permit electronic attestation.
Attach Supporting Records
Include loss runs, claim denials, or internal incident logs as annexes. Comprehensive attachments simplify carrier verification and reduce follow-up inquiries that extend underwriting cycles.

eSignature platform comparison for executing Insurance No Losses Statements

Compare core pricing and capabilities for commonly referenced vendors; signNow appears first per vendor ordering rules.

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 Yes, 7-day trial Varies Varies Varies Varies
Bulk Send Yes (Business Premium) Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently asked questions about Insurance No Losses Statements

Answers to common questions about validity, notarization, digital signing, and storage for no-loss attestations.


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