Insurance SONL Nat Gen

INSURANCE SONL NAT GEN

Insured / Applicant Information

Date of Birth:    Phone:    Email:

Policy Details

Policy Number:    Policy Type:

Coverage Amount:    Deductible:    Annual Premium:

Policy Period From:    To:

Coverage Declaration — Statement of No Loss

By signing this Statement of No Loss, the Insured certifies that during the Policy Period stated above there have been no losses, claims, incidents, occurrences or circumstances that are reasonably likely to result in a claim under the policy identified above, except as fully disclosed herein.

Please indicate that no losses of each type have been sustained during the policy period by checking the applicable boxes:

No property damage losses
No liability claims or suits
No automobile-related losses
No workers' compensation claims
No other losses (specify)

Disclosure of Losses (If Any)

If any loss, claim, incident or circumstance that could give rise to a claim has occurred during the policy period, provide a complete description below. Failure to disclose material information may result in denial of coverage or other remedies under the policy.

Exclusions, Representations and Acknowledgements

This Statement of No Loss is a representation made by the Insured for underwriting and policy administration purposes. It does not amend, extend, or otherwise change the terms, conditions, exclusions or limits of the underlying insurance policy. The insurer reserves all rights under the policy to investigate and adjust claims and to apply policy terms.

The Insured acknowledges that any material misrepresentation or omission in this Statement may result in cancellation, rescission, denial of coverage, or other remedies permitted by law and the policy. The Insured consents to the release of this Statement to claims adjusters, underwriters, and reinsurers for the purposes of evaluation and underwriting.

I acknowledge and agree to the statements above.

Beneficiary Information (If applicable)

Beneficiary Name:

Relationship:    Allocation Percentage:

Certification

I certify, under penalty of perjury or pursuant to applicable statutory provisions, that the foregoing statements are true, correct and complete to the best of my knowledge and belief. I understand that this Statement will be relied upon by the insurer in making underwriting and coverage decisions. I authorize the insurer to make any inquiries reasonably necessary to verify the accuracy of this Statement.

I further acknowledge that this Statement may be retained in the insurer's files and used in connection with any future claim arising under the policy.

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