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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Agency Information

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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.*
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Avery Claims

Life can be complicated but protecting the things that matter doesn’t have to be. For more than 120 years, Avery has been a trusted insurance source for families and businesses alike. By using a consultative approach we uncover areas of vulnerability so our clients can sleep at night. We will take the time to get to know you and build a comprehensive portfolio of asset protection unique to you. If you’re looking for a partner to help protect what matters most in this wonderful journey we call life, you’ve come to the right place.

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