Transcription of I CERTIFY THAT I AM NOT AWARE OF ANY LOSSES, …
1 acord 37 (2008/01) 1996-2008 acord CORPORATION. All rights AND TIMEWITNESSDATE AND TIMERECEIPT$AMOUNT RECEIVED BY:PRODUCERAPPLICANT'S SIGNATUREI CERTIFY THAT I AM NOT AWARE OF ANY LOSSES, ACCIDENTSOR CIRCUMSTANCES THAT MIGHT GIVE RISE TO A CLAIM UNDERTHE INSURANCE POLICY WHOSE NUMBER IS SHOWN ABOVE,FROM 12:01 AM DATEDATE AND TIME SIGNEDSTATEMENT OF NO LOSSE-MAILADDRESS:AGENCY CUSTOMER ID:CODE:SUBCODE:PHONE(A/C, No, Ext):CONTACTNAME:AGENCY(A/C, No):FAXNAIC CODECARRIERPOLICY NUMBERNAMED INSUREDAPPROVED BYThe acord name and logo are registered marks of acord
