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? *
MM slash DD slash YYYY
What is the current time? **
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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.*
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Hellen Hill

Hellen joined the Avery team in the summer of 2022 as a risk specialist in the commercial division of the agency. Prior to joining Avery, Hellen worked for many years as a commercial lines manager servicing large, complicated accounts. She took a break from her insurance career to earn her Master’s Degree in Education from Franklin Peirce University. After a stint in teaching, she decided to return to her roots and is happy to be back in insurance. Hellen hails from Concord, NH but recently relocated to Tampa, FL with her son.

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