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I CERTIFY THAT I AM NOT AWARE OF ANY LOSSES, …

The ACORD name and logo are registered marks of ACORDAPPROVED BYNAMED INSUREDPOLICY NUMBERCARRIERNAIC CODEFAX(A/C, No):AGENCYNAME:CONTACT(A/C, No, Ext):PHONESUBCODE:CODE:AGENCY CUSTOMER ID:ADDRESS:E-MAILSTATEMENT OF NO LOSSDATE AND TIME SIGNEDCANCELLATION 12:01 AM ONTHE INSURANCE POLICY WHOSE NUMBER IS SHOWN ABOVE,OR CIRCUMSTANCES THAT MIGHT GIVE RISE TO A CLAIM UNDERI CERTIFY THAT I AM NOT AWARE OF ANY LOSSES, ACCIDENTSAPPLICANT'S SIGNATUREPRODUCERAMOUNT RECEIVED BY:$RECEIPTDATE AND TIMEWITNESSDATE AND TIME 1996-2008 ACORD CORPORATION. All rights 37 (2008/01)

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):

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Transcription of I CERTIFY THAT I AM NOT AWARE OF ANY LOSSES, …

1 The ACORD name and logo are registered marks of ACORDAPPROVED BYNAMED INSUREDPOLICY NUMBERCARRIERNAIC CODEFAX(A/C, No):AGENCYNAME:CONTACT(A/C, No, Ext):PHONESUBCODE:CODE:AGENCY CUSTOMER ID:ADDRESS:E-MAILSTATEMENT OF NO LOSSDATE AND TIME SIGNEDCANCELLATION 12:01 AM ONTHE INSURANCE POLICY WHOSE NUMBER IS SHOWN ABOVE,OR CIRCUMSTANCES THAT MIGHT GIVE RISE TO A CLAIM UNDERI CERTIFY THAT I AM NOT AWARE OF ANY LOSSES, ACCIDENTSAPPLICANT'S SIGNATUREPRODUCERAMOUNT RECEIVED BY:$RECEIPTDATE AND TIMEWITNESSDATE AND TIME 1996-2008 ACORD CORPORATION. All rights 37 (2008/01)


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