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i certify that there have been no losses, accidents or circumstances that might give rise to a claim under the insurance policy whose number is shown above, from 12:01 am on to . receipt $ amount received by: acord 37 (1/96) oc acord corporation 1996 cancellation date date and time signed applicant's signature producer witness date and.

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the acord name and logo are registered marks of acord approved by named insured policy number carrier naic code fax (a/c, no): agency name: contact (a/c, no, ext): phone code: subcode: agency customer id: address: e-mail statement of no loss cancellation date date and time signed from 12:01 am on to . the insurance policy whose number is shown.

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acord 37 (1/96) c acord corporation 1996 witness date and time receipt $ amount received by: producer applicant's signature i certify that there have been no losses, accidents or circumstances that might give rise to a claim under the insurance policy whose number is shown above, from 12:01 am on to . cancellation date date and time signed policy #

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no loss has occurred for which coverage might be claimed under my POLICY NUMBER _____between the date of _____12:01 a.m. (local time) and _____. I understand that Ascendant Commercial Insurance is relying solely upon this statement of no losses as an inducement to reinstate my policy. I further understand if a

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TITLE. ACORD 37 (2008/01) STATEMENT OF NO LOSS. ACORD 37, Statement of No Loss is used when: * A policy issued by your agency has been cancelled, or has lapsed, because premium for. the policy was not paid in time; * The former insured desires to pay the delinquent premium and reinstate insurance. without a lapse in coverage; and.

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Created Date: 11/11/2015 10:24:53 AM

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The ACORD name and logo are registered marks of ACORD RECEIPT I CERTIFY THAT I AM NOT AWARE OF ANY LOSSES, ACCIDENTS OR CIRCUMSTANCES THAT MIGHT GIVE RISE TO A CLAIM UNDER THE INSURANCE POLICY WHOSE NUMBER IS SHOWN ABOVE, FROM 12:01 AM ON TO . STATEMENT OF NO LOSS. Title: Statement Of No Loss (2008/01)

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statement of no loss producer insured's name telephone number: company: approved by: code: sub code: policy # i certify that there have been no losses, accidents or circumstances that might give rise to a claim under the insurance policy whose number is shown above, from 12:01 am on to . receipt $ amount received by:

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Title: Customer Service Home Page Author: ben.lynds Created Date: 4/14/2011 8:00:17 AM

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LOCATION OF LOSS POLICE OR FIRE DEPARTMENT CONTACTED STREET: CITY, STATE, ZIP: REPORT NUMBER COUNTRY: DESCRIBE LOCATION OF LOSS IF NOT AT SPECIFIC STREET ADDRESS: DESCRIPTION OF ACCIDENT (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) INSURED INSURED'S MAILING ADDRESS PRIMARY E-MAIL ADDRESS:

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How to fill out statement of no loss: 01. Gather all necessary information, such as personal details and the reason for needing the statement of no loss. 02. Contact the relevant department or organization to request the statement of no loss. 03. Fill out the required forms or documents accurately and completely.

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ACORD Forms increase your efficiency. Since our first paper form was released in 1971, ACORD has provided the standard forms used by the insurance industry. ACORD Forms are now available in a variety of formats, including printable PDF, electronic fillable, and eForms. Using ACORD's standardized Forms allows for increased efficiency, accuracy.

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ACORD 37 Statement of No Loss. Use the clickable sections in the form below to find corresponding fields in Sagitta. When you have a question about a field on the form, click its section to access the list of Sagitta fields that populate that section of the form. ACORD 37 2008/01 Statement of No Loss ©

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statement of no loss 21515 hawthorne blvd suite 440 torrance, ca 90503 agency code: sub code: approved by i certify that i am not aware of any losses, accidents or circumstances that might give rise to a claim under the insurance policy whose number is shown above, from 12:01 am on to . cancellation date date and time signed applicant's.

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i certify that there have been no losses, accidents or circumstances that might give rise to a claim under the insurance policy whose number is shown above, from 12:01 am on to . acord statement of no loss. author: suzanne cowan created date: 8/15/2012 4:19:52 pm title.