Statement Of No Loss

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What is your first name? *
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What is your address? **
What is your address? *

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? **
What is the current time? *
:
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

Justine Miley, AIC, AINS

In the fall of 2022, Justine Miley joined the agency as a Senior Claims Advisor. In this newly-created role, Justine will oversee all aspects of the claims process, conduct trend analysis and reserve reduction efforts, and will proactively educate clients on the impact claims have on their overall insurance program.

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