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? *
MM slash DD slash YYYY
What is today's date? *
MM slash DD slash YYYY
What is the current time? **
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:
Please sign your name in the box below. *
Clear Signature

Agency Information

Please enter the insurance agency's name. *
What is the address of the agency? **
What is the address of the agency? *
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

Danielle Rice

As Director of Strategy and Engagement at Avery Insurance, Danielle serves as the bridge between carrier performance and client experience, aligning strategic vision with elevated service to create long-term value on both sides of the relationship. With over 20 years of commercial insurance expertise, Danielle is responsible for developing and managing high-level relationships with insurance carriers and the agency’s most elite clientele. In her role, Danielle plays a vital part in positioning Avery for sustained success in an evolving marketplace. She oversees carrier strategy, appetite alignment, portfolio performance, and contractual negotiations to ensure optimal placement and market access. Simultaneously, Danielle acts as a trusted advisor to several of Avery’s clients, delivering transformative risk solutions, strengthening long-term partnerships, and fulfilling the Avery Promise with every engagement. Danielle resides in Belmont, New Hampshire with her family. Outside the off

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