Statement Of No Loss

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Policy Information

Please enter the name of the insurance company the canceled policy was placed with. *
Please enter the policy number of the canceled insurance policy. *

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. *
What date was the insurance policy canceled? *
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What is today's date? *
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Clear Signature

Agency Information

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Please enter the insurance agent's name. *
<font size="2" color="gray">Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.*
Agent Save & Continue

Michael Battle

Michael W. Battle earned a Bachelor of Business Administration (Risk Management) degree from Southern Methodist University. For the last 43 years, he has been a Partner and Director at Keen Battle Mead & Company. Michael has served on Boards of Directors, which include being Past-President of the Independent Insurance Agents of Dade County, Past-President of Riviera Country Club, Past-President of Snapper Creek Lakes Homeowners Association, Past-Chairman of Habitat for Humanity of Greater Miami, Past-Director of the Two Hundred Club of Miami. His Board service on a national business level has included: Director of The Council of Insurance Agents and Brokers, Executive Council of Crum & Forster Insurance Company, and President of Sunshine Insurance Limited, a Bermuda Reinsurance Company. Michael has also served the Florida Association of Insurance Agents as Vice Chair of the Automation Committee, the Legislative Committee, and Chairman of the Local Boards Committee.

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