Insurance SONL Document

INSURANCE STATEMENT OF NO LOSS (SONL)

Insured Name:    Policy Number:

1. Insured Information

2. Policy Details

Policy Type: Property Liability Auto Other

Policy Period: From to

3. Statement of No Loss

By signing below, the undersigned insured certifies that during the policy period set forth above there have been no incidents, occurrences, claims, suits, demands, notices of circumstances, or any facts or situations that are reasonably likely to give rise to a claim under the referenced policy, except as disclosed in this document.

Please indicate one: No loss to report for the entire policy period One or more losses/incidents to report (complete below)

4. Documentation Checklist

Attach or provide the following if applicable: Policy declaration page Photographs or other documentation of condition Previous loss reports or claim correspondence

5. Beneficiary / Payee Information

Complete beneficiary/payee for receipt of any policy payments or recoveries (if applicable).

6. Exclusions and Acknowledgements

The undersigned acknowledges that coverage is subject to the terms, conditions, exclusions, and limits of the policy. Typical exclusions may include but are not limited to deliberate acts, wear and tear, pollution, war, nuclear hazard, and losses arising from dishonest or fraudulent acts by the insured. This Statement does not expand coverage or alter policy terms.

Acknowledgement: I have read and understand the applicable policy terms, conditions, and exclusions. I certify that the statements in this form are true and complete to the best of my knowledge.

7. Certification and Authorization

I certify under penalty of insurance policy remedies and applicable law that the information contained in this Statement of No Loss is true, complete, and made in good faith. I understand that any material misrepresentation, omission, or false statement may result in denial of coverage, rescission of the policy, adjustment of premiums, or other remedies permitted by law and policy provisions. I authorize the insurer to verify any information provided herein and to obtain pertinent records to the extent permitted by law.

I agree to promptly notify the insurer in writing of any change in circumstances that would render this Statement inaccurate during the current policy period.

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