Transcription of ACORD STATEMENT OF NO LOSS
1 TMPRODUCERINSURED'S NAMETELEPHONE NUMBER:COMPANY:APPROVED BY:POLICY #CODE:SUBCODE:CANCELLATION DATEDATE AND TIME SIGNEDAPPLICANT'S SIGNATUREPRODUCERWITNESSDATE AND TIMEDATE AND TIME$AMOUNT RECEIVED BY: ACORD 37 (1/96) ACORD CORPORATION 1996 RECEIPTI CERTIFY THAT THERE HAVE BEEN NO LOSSES, ACCIDENTS ORCIRCUMSTANCES THAT MIGHT GIVE RISE TO A CLAIM UNDERTHE insurance POLICY WHOSE NUMBER IS SHOWN ABOVE,FROM 12:01 AM OF NO loss