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Acord-37
STATEMENT OF NO LOSS
Agency
PHONE (A/C,No,Ext):
E-MAIL ADDRESS:
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CONTACT NAME:
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CARRIER
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NAIC CODE
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NAMED INSURED
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POLICY NUMBER
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FAX(A/C,No):
(Required)
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CODE:
(Required)
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SUBCODE:
(Required)
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APPROVED BY
(Required)
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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
DATE AND TIME SIGNED
APPLICANT'S SIGNATURE
RECEIPT
$
AMOUNT RECEIVED BY
PRODUCER
WITNESS
DATE AND TIME
MM slash DD slash YYYY