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Insurance Statement of No Losses

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INSURANCE STATEMENT OF NO LOSSES

Insured / Applicant Information

Policy Details

Statement Period: From through

Coverage Confirmation

The undersigned hereby represents and warrants that, during the Statement Period specified above, the insured has not sustained, reported, or been subject to any loss, claim, incident, suit, demand, or circumstance which could reasonably be expected to give rise to a claim under the referenced policy, except as specifically disclosed below.

Exclusions and Material Disclosures

This Statement of No Losses does not alter, amend, or waive any policy exclusions, conditions, or warranties. The undersigned acknowledges that failure to disclose a material fact, loss, or circumstance may be grounds for denial of coverage, premium adjustment, policy cancellation or rescission, and may subject the undersigned to civil or criminal penalties under applicable law.

Beneficiary Information (if applicable)

Complete this section only if the policy provides for a named beneficiary. If not applicable, leave blank.

Declaration and Certification

I, the undersigned, certify that to the best of my knowledge and belief all statements in this document are true, complete, and accurate. I further certify that during the Statement Period there were no losses, accidents, claims, suits, demands, occurrences, or circumstances, known to me, that would give rise to a claim under the policy identified above, except as fully disclosed in this statement. I understand that any material misstatement, omission, or concealment of fact may constitute fraud and may result in denial of coverage, policy cancellation, rescission, premium adjustment, or other remedies available to the insurer by law or in equity.

Authorization: I authorize the insurer and its agents to make such investigations as are necessary to verify the statements made herein, including inspection of records and inquiry of third parties, and I consent to release of such information to insurers and reinsurers for underwriting or claim handling purposes.

Applicant Printed Name:

Signature:

Date:

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What an Insurance Statement of No Losses Is

An Insurance Statement of No Losses is a signed declaration by the insured confirming that no claims, incidents, or covered losses occurred under a specified policy during a defined period. Carriers, agents, and auditors typically request this document at renewal, during endorsements, or as part of underwriting reviews. The statement identifies the insured and policy, specifies start and end dates, contains an affirmative declaration, and is signed and dated; some insurers require notarization or witness attestation for verification.

Why this document matters for underwriting and renewals

It provides a concise, verifiable record that no policy-covered incidents occurred during the stated period, simplifying underwriting and renewal reviews and potentially preserving favorable premium terms while reducing insurer follow-up.

Why this document matters for underwriting and renewals

Who commonly completes and signs the statement

Insurance companies, agents, brokers, risk managers, and policyholders commonly complete or request this statement during renewal underwriting or coverage reviews.

  • Insurance underwriters: Confirm claim-free periods for rating and premium decisions.
  • Commercial policyholders: Provide proof of no losses for fleet, property, or general liability.
  • Independent agents: Submit statements to multiple carriers during placement or mid-term audits.

Use consistent formatting and the insured's official name on every submission to avoid identity checks and to speed insurer processing.

Essential sections to include in the statement

Core sections establish identity, coverage, time period, affirmation of no claims, signature, and certification or notarization when required for verification.

Insured Name

Enter the full legal name of the insured exactly as on the policy. Mismatched names can delay verification or trigger requests for corrective documentation.

Policy Details

Provide policy number, insurer name, coverage type, and policy effective and expiration dates. Accurate policy data ties the statement to a specific contract.

Statement Period

Specify the precise start and end dates for the claim-free period using MM/DD/YYYY format. Ambiguous ranges cause processing delays or rejection.

Declaration

A clear affirmative sentence that no covered losses or claims occurred during the stated period, signed by an authorized representative under penalty of perjury if required.

Signature Block

Signer must print name, title, date, and sign. If signing on behalf of an entity, include authority statement or corporate title to show authority.

Notary / Attestation

If the insurer requires it, include notarization or a witness signature and date. Remote notarization may be accepted where state law permits.

Step-by-step: complete and deliver the statement

Complete the statement in order: identify parties, set the period, declare no losses, sign, and deliver to the requesting insurer.

  • 01
    Gather info: Collect policy number, declarations page, and loss runs.
  • 02
    Enter dates: Use exact MM/DD/YYYY start and end dates.
  • 03
    Declare status: State no losses or claims during the period.
  • 04
    Sign & notarize: Sign with authority and notarize if insurer requires.

Where to send or file the completed statement

Typical submission routes depend on the insurer's process: email, secure portal, agent upload, or mailed original if notarization is required.

  • Email: Send signed PDF to the insurer's claims or underwriting address.
  • Company Portal: Upload via carrier secure portal with policy reference.
  • Agent Upload: Provide statement to the broker or agent for submission.
  • Mail (Original): Mail original notarized copy when originals are required.

Digital workflow settings to collect and verify statements

Set up a digital workflow to collect, authenticate, and archive statements with required fields and signer verification.

Field Configuration
Authentication Email link; SMS OTP; optional knowledge-based verification
Required fields Insured name, policy number, period, declaration, signer info
Attachments Allow PDF uploads for loss runs and declarations
Retention Store signed copy in secure repository for required period

Technical capabilities to confirm before e-submitting

Verify platform capabilities for secure signing, identity verification, and storage that meet insurer and regulatory expectations.

  • File formats: PDF and DOCX accepted
  • Authentication: Email, SMS, KBA options
  • Integrations: Integrates with Salesforce, NetSuite, Box

Vendor pricing snapshot for electronic signature providers

Comparison of common eSignature vendors and core plan differences to help choose a platform for collecting signed Insurance Statements of No Losses.

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 plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Yes Yes Yes Yes
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Required identifying information and short-format checklist

Insured: Full legal name
Policy: Policy number and carrier
Period: Exact start and end dates
Declaration: Affirmative no-loss statement
Signature: Signer name and title
Attestation: Notary or witness if required

Common mistakes that delay acceptance

  • Using informal language or ambiguous date ranges like 'last year' which delays insurer verification and triggers requests for clarification.
  • Mismatched names between the statement and the policy lead to identity checks, possible re-submission, or denial of acceptance.
  • Failure to include policy number or insurer details forces manual matching and increases processing time significantly.
  • Signing without authority or failing to attach proof of signatory authority exposes the statement to rejection or legal challenge.

Short list of legal and contractual risks

Coverage Risk: Coverage denial or rescission
Fraud Liability: Civil or criminal fraud exposure
Perjury Exposure: State perjury statutes may apply
Claims Adjustment: Delayed or reduced claim payments
Contractual Penalties: Policy terms may include fines or surcharge
Data Privacy: HIPAA exposure if PHI mishandled (45 CFR §164.502)

Typical timing expectations and submission deadlines

Follow insurer-specified deadlines for best outcomes; common triggers include renewals, audits, or specific carrier requests.

At Policy Renewal:

Provide statement at renewal request or prior to renewal

Mid-Term Audit:

Submit within insurer's stated audit deadline, often 10–30 days

On Request:

Provide within the deadline in the carrier's request letter

After Incident (if requested):

If insurer asks post-incident, supply promptly with supporting documents

Retention & Production:

Produce originals within 30 days for audits unless carrier states otherwise

Key processing milestones from request to archive

A simple milestone flow helps track responsibilities and ensures the statement is authenticated, accepted, and retained for audits or claims.

01

Request Received

Record request date and deadline; begin document collection.

02

Draft Statement

Populate insured details, period, and declaration accurately.

03

Authentication

Signer signs and notarizes or completes RON session as required.

04

Submit & Archive

Send to insurer and retain exportable signed copy with audit trail.

Two practical use examples

Two example scenarios illustrate practical uses of an Insurance Statement of No Losses in commercial and personal lines.

Commercial Fleet

A national trucking firm supplies a no-loss statement annually to maintain preferred commercial auto rates and avoid audits.

  • Used at renewal to confirm 12 months claim-free status.
  • The carrier accepted the electronic statement with attached loss runs, enabling a streamlined renewal and preventing a mid-term audit; the company saved administrative time and avoided premium increases tied to incomplete records.

Individual Homeowner

A homeowner provides a signed no-loss statement to a mortgage servicer after policy transfer to confirm no open claims.

  • Submitted to satisfy servicer due diligence.
  • The notarized statement plus a declarations page resolved a coverage question quickly and prevented temporary hold on disbursement for escrow or loan processing.

Frequently asked questions and troubleshooting

Answers to common questions about validity, notarization, signature methods, and record retention for Insurance Statements of No Losses.


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