Can an insurer accept an electronic signature?

Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. §7001) and UETA where adopted, provided the four legal elements—intent, consent, attribution, and retention—are satisfied.

Is notarization required for these statements?

Not generally required unless the carrier or a specific state law demands it; verify contract language and state rules. Use RON where permitted and when notarization is explicitly requested.

Who can sign on behalf of a corporate insured?

An officer or authorized representative should sign. Document the signer’s title and authority; carriers may request a board resolution or power of attorney if authority is unclear.

What if a loss is discovered after signing?

If a loss occurred and the statement was incorrect, notify the carrier immediately. Failing to disclose can affect coverage, lead to premium adjustments, or expose the signer to legal risk.

How should signed statements be stored?

Retain signed copies in a secure, auditable system with exportable records. Follow applicable retention rules such as IRS records (IRC §6501(a)) and HIPAA retention where relevant (45 CFR §164.530(j)).

Can a statement be revoked or amended?

Yes; execute a signed amendment or revocation and circulate to the same recipients. Keep the original and amendment together to preserve auditability and evidentiary value.

Electronic Signature
Templates
Insurance
Insurance Statements of No Losses

Insurance Statements of No Losses

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

INSURANCE STATEMENT OF NO LOSSES

Applicant / Insured Information

Insured Name Mailing Address

Date of Birth / Entity Formation Date: Telephone:

Entity Type (select all that apply)

Individual Corporation LLC Partnership Other:

Policy Details

Insurer Name:

Policy Number

Policy Type: Coverage Limit:

Deductible: Premium:

Policy Period From: To:

Statement of No Losses

For the policy period specified above, the undersigned declares and certifies that no claim, suit, incident, loss, accident, or occurrence which would reasonably give rise to a claim under the policy has been made by or against the Insured, nor is the Insured aware of any facts or circumstances which could reasonably be expected to result in such a claim, except as specifically disclosed below.

Coverages (check if NO losses for each coverage)

Property (No losses) General Liability (No losses) Automobile (No losses) Workers' Compensation (No losses) Professional Liability (No losses)

If any coverage above has experienced a loss during the policy period, check the corresponding box and provide a full description of each loss in the Loss Details section below. Failure to disclose a known loss may void coverage or result in denial of coverage for that loss.

Loss Details (if applicable)

There were losses, incidents, or claims during the stated policy period: Yes (check if applicable)

Describe each loss, claim, or incident (if any) Estimated Amount Paid or Reserved for each loss Documentation Checklist (select attached items)

Police report Photographs Repair estimate Medical records Other:

Exclusions and Notices

The undersigned acknowledges that this Statement does not amend, extend, or alter any policy terms, conditions, limitations or exclusions. The Insurer retains all rights to revise underwriting decisions based upon information discovered subsequent to the signing of this Statement. Claims arising from prior acts, known circumstances, intentional acts, fraud, or criminal conduct are excluded where applicable by policy language.

Notice: A material misrepresentation or omission in this Statement may result in rescission of coverage, denial of claims, forfeiture of premium, or other legal remedies available to the Insurer. The undersigned certifies that all answers are complete and true to the best of their knowledge and belief.

Beneficiary Information (if applicable)

Provide primary beneficiaries who should receive notice or settlement proceeds in the event of claimable loss where beneficiary designation is permitted by the policy.

Beneficiary 1 — Full Name

Relationship: Percentage:

Beneficiary 2 — Full Name

Relationship: Percentage:

Declaration and Certification

By signing below, the undersigned declares under penalty of law that the foregoing statements are true and complete. The undersigned authorizes the Insurer to investigate, verify, and obtain records as necessary to evaluate the accuracy of this Statement, including but not limited to prior loss histories, claims records, and public or private databases. The undersigned affirms that no facts have been willfully withheld and that all material information known to the insured has been disclosed herein.

The undersigned acknowledges that this Statement may be relied upon by the Insurer for underwriting, rating and acceptance of risk, and that falsification or omission may subject the undersigned to civil or criminal penalties as permitted by law.

Printed Name:

Signature:

Date:

Authority: Signatory affirms they are authorized to execute this Statement on behalf of the Insured and that the information contained herein is true and complete.

What an Insurance Statement of No Losses Is

An Insurance Statement of No Losses is a signed declaration from a policyholder or insured party confirming no claims, incidents, or losses occurred during a specified period. Insurers commonly request it at renewal, during underwriting, or before issuing a new policy to verify risk exposure. The document typically identifies the insured, policy numbers, coverage dates, and a clear statement that no losses occurred, and it is often accompanied by supporting policy documents or declarations pages.

Why insurers and policyholders use a No-Loss Statement

The statement clarifies exposure for underwriting and premium calculations, reduces processing time for renewals, and documents a claimant’s loss history for audit purposes. Properly completed, it supports accurate policy placement and helps avoid disputes about prior claims during the policy term.

Common users and participants

Parties who prepare or rely on these statements include insurers, brokers, and insured businesses or individuals.

Insurance carriers and underwriters verifying prior-loss history and exposure for pricing decisions.
Insurance brokers and agents preparing renewal packages and collecting supporting documentation from clients.
Policyholders — businesses or individuals — certifying that no covered loss occurred during the stated period.

Each party has a distinct role: the insured provides the factual attestation, brokers collect and forward forms, and carriers use the statement to assess risk and confirm coverage eligibility.

Essential components of a professional No-Loss Statement

A complete statement organizes factual identifiers and clear attestations so insurers can make underwriting decisions without follow-up requests.

Insured ID

Full legal name and entity type, DBA where applicable, and tax identification or policyholder number to ensure the attestation ties to the correct policy record and legal entity.

Policy Details

Carrier name, policy number, coverage type, and exact coverage period so the statement is unambiguous about which policy term is being attested to.

No-Loss Declaration

A concise affirmative sentence stating that no claims, incidents, or losses occurred during the stated period, including any material facts the insurer specifically requested.

Effective Dates

Start and end dates for the attested period using MM/DD/YYYY format; these dates determine the window the insurer will treat as loss-free.

Signature Block

Printed name, title, signature, and date for the signing party; include company officer title and contact details to confirm authority and enable follow-up.

Attachments

Relevant policy declarations, loss runs, or prior correspondence attached as exhibits to corroborate the no-loss assertion and speed underwriting review.

Security and compliance details to include

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest

Access Control: Role-based access and audit logging

Audit Trail: Timestamps, IP, and action history

HIPAA BAA: Execute BAA if PHI is included

ESIGN/UETA: Meets ESIGN and UETA legal tests

Retention: Secure storage with versioning

Step-by-step: completing a No-Loss Statement

Follow these steps to create an accurate, underwriter-ready statement and avoid common delays.

01

Gather policy data: Collect carrier name, policy number, and coverage dates.
02

Draft declaration: Write a single clear sentence affirming no claims occurred.
03

Attach proof: Include declarations page and loss runs when available.
04

Sign and date: Authorized signer completes signature, printed name, title, and date.

Configuring a digital workflow for No-Loss Statements

A standardized digital workflow reduces back-and-forth and ensures signatures and attachments are captured correctly.

Field	Configuration
Policy Number	Required text field; validate length and characters.
Coverage Period	Two date fields (MM/DD/YYYY) with validation.
No-Loss Checkbox	Required boolean field linked to signature confirmation.
Attachments	PDF upload field; limit to declared file types.

Where completed statements go and who reviews them

Know the typical routing so parties can monitor status and avoid misrouting or delays.

Submit to Broker: Broker receives statement and verifies attachments.
Forward to Carrier: Carrier underwriting team adds to file and reviews.
Underwriter Review: Underwriter confirms loss history and pricing impact.
File Retention: Carrier stores in policy system and document archive.

Digital delivery, signing, and format requirements

Use common formats and integrations to reduce friction and ensure documents open for all reviewers.

File Formats: PDF or DOCX preferred; ensure flattened PDF for final storage.
Authentication: Email or SMS code for signer verification.
Integrations: Connectors to CRM or policy admin systems

Platforms that support audit trails, document attachments, and standard integrations (CRM, policy admin, cloud storage) improve processing speed and reduce manual entry.

Timing to provide and renew No-Loss Statements

Timing varies by insurer and transaction; plan submissions to align with renewal cycles and underwriting requests.

On Renewal:

Often required at policy renewal or when underwriting requests updated exposure.

Upon Request:

Provide promptly when a carrier or broker asks to avoid coverage delays.

Before New Policy:

Requested prior to binding for new or transferred coverage.

Claim Period:

Not a substitute for immediate claim reporting if a loss occurs.

Retention Notice:

Keep a signed copy according to internal retention policies.

Common mistakes that delay underwriting

Incomplete policy identifiers that force clarifying questions and delay acceptance by underwriters.
Using imprecise date ranges rather than exact MM/DD/YYYY dates, which can create ambiguity about the covered period.
Missing attachments such as declarations pages or loss runs, causing the carrier to request supplemental records.
Signatory lacks authority or omits title, prompting the carrier to require an officer-level signature or corporate resolution.

Consequences of incorrect or false statements

Coverage Denial: May result in claim denial

Policy Rescission: Carrier could rescind policy

Premium Adjustment: Retroactive premium change possible

Regulatory Risk: State regulators may investigate

Legal Liability: Potential civil exposure for misrepresentation

Contract Breach: Broker agreement implications

Representative examples of digital attestations in practice

Organizations use digital statements to accelerate renewals and reduce manual follow-up in real operational settings.

Martin Properties

Tim Martin, Founder, Martin Properties

used online attestations and mobile signing to finalize renewal paperwork quickly
The firm processed and executed statements online with compliance and security, reducing back-and-forth with carriers and speeding renewals.

Fertility Centers

John Butler, Founder, Fertility Centers of Illinois

adopted digital workflows for client-facing forms and attestations
The organization relied on secure, auditable signatures to keep patient and operational records complete while complying with security requirements.

eSignature vendor pricing and capability snapshot for attestations

This vendor comparison highlights common price points and core capabilities relevant to executing Insurance Statements of No Losses; signNow is listed first per platform comparison format.

	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	Varies	Varies	Varies
Bulk Send	Yes	Varies	Varies	Varies	Varies
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies	Varies	Varies

Frequently asked questions about No-Loss Statements

Answers to common questions about signing, notarization, legal validity, and handling when circumstances change.

Need help? Contact support

Can an insurer accept an electronic signature?
Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. §7001) and UETA where adopted, provided the four legal elements—intent, consent, attribution, and retention—are satisfied.
Is notarization required for these statements?
Not generally required unless the carrier or a specific state law demands it; verify contract language and state rules. Use RON where permitted and when notarization is explicitly requested.
Who can sign on behalf of a corporate insured?
An officer or authorized representative should sign. Document the signer’s title and authority; carriers may request a board resolution or power of attorney if authority is unclear.
What if a loss is discovered after signing?
If a loss occurred and the statement was incorrect, notify the carrier immediately. Failing to disclose can affect coverage, lead to premium adjustments, or expose the signer to legal risk.
How should signed statements be stored?
Retain signed copies in a secure, auditable system with exportable records. Follow applicable retention rules such as IRS records (IRC §6501(a)) and HIPAA retention where relevant (45 CFR §164.530(j)).
Can a statement be revoked or amended?
Yes; execute a signed amendment or revocation and circulate to the same recipients. Keep the original and amendment together to preserve auditability and evidentiary value.

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