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Acord-37
STATEMENT OF NO LOSS
Agency
(Required)
NAMED INSURED
(Required)
CONTACT NAME:
(Required)
CARRIER
(Required)
NAIC CODE
(Required)
PHONE (A/C,No,Ext):
(Required)
POLICY NUMBER
(Required)
FAX(A/C,No):
(Required)
E-MAIL ADDRESS:
(Required)
CODE:
(Required)
SUBCODE:
(Required)
APPROVED BY
(Required)
AGENCY CUSTOMER ID:
(Required)
I CERTIFY THAT I AM NOT AWARE OF ANY LOSSES, ACCIDENTSOR CIRCUMSTANCES THAT MIGHT GIVE RISE TO A CLAIM UNDER THE INSURANCE POLICY WHOSE NUMBER IS SHOWN ABOVE, FROM 12:01 AM ON
CANCELLATION DATE
(Required)
DATE AND TIME SIGNED
(Required)
APPLICANT'S SIGNATURE
(Required)
RECEIPT
$
(Required)
AMOUNT RECEIVED BY
(Required)
PRODUCER
(Required)
WITNESS
(Required)
DATE AND TIME
(Required)
MM slash DD slash YYYY