Statement Of No Loss
Please retype the following statement in the text box below.
"I certify that there have been no losses, accidents or circumstances that might give rise to a claim under the insurance policy referenced in this form from 12:01 AM on the date the policy was canceled, which is referenced in this form, to today's date and time, which is also referenced in this form."
Enter the statement of no loss in the box below. *
Please sign your name in the box below. *