A no loss statement may be requested when a business insurance policy is being renewed, reviewed, or considered for reinstatement after a cancellation or lapse.
It allows the business to certify that no losses, accidents, claims, damages, or known claim-related circumstances occurred during a specific period.
This free printable no loss statement provides a clean, professional form for organizing that information.
It also includes a separate guidance page with practical recommendations for reviewing the certification period, completing the form carefully, and communicating with the insurance carrier or agent.
Printable Details
Title: No Loss Statement.
Used For: Certifying that no known losses, accidents, claims, damages, or potentially claim-producing circumstances occurred during a stated insurance period.
Page Length: .
Paper Size: 8.5 × 11 in (portrait).
File Size: 226 KB.
File Type: PDF.
Color: RGB and Black & White.
License: Personal and internal use by the downloader’s own business.
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At a Glance
Overview
The first page contains the formal no loss statement. It includes fields for the named insured, business address, contact information, insurance carrier, agent or producer, policy number, policy type, lapse date, and requested reinstatement date.
The certification section states that, to the best of the signer’s knowledge, no losses, accidents, claims, damages, or circumstances that could reasonably lead to a claim occurred during the specified period. Separate From and To fields are included so the exact period can be recorded clearly.
The signature area provides space for the authorized representative’s signature, printed name, business title, signing date, and signing time. A compact section for agent or carrier use is also included.
Page two is titled “Before You Submit.” It includes general recommendations for confirming insurer requirements, checking business records, reviewing possible incidents, completing the form accurately, and documenting the insurer’s response.
Page three contains an extended notice explaining the limitations of the template, the importance of accurate disclosure, and the personal-use licensing terms.
How to Use the No Loss Statement
Begin by contacting your insurance agent, broker, or carrier. Ask whether they require their own no loss statement form. Some companies may require specific wording, a state fraud notice, a particular signature format, payment, or supporting documentation.
If the general template is acceptable, complete the business and policy fields using the information shown on your insurance documents. Avoid shortened names or informal variations that may not match the policy record.
Next, identify the exact certification period. This may begin when the previous coverage ended and continue until the date or time requested by the insurer. Confirm whether both dates and times are required.
Before signing, review the business’s records for the entire period. This may include incident reports, vehicle records, customer complaints, injury reports, property damage, employee reports, emails, demands, and events that have not yet developed into a formal claim.
Only an authorized representative should sign the form. Keep a copy of the completed statement and record how and when it was submitted.
Tips for Communicating With the Insurer
Ask direct questions before sending the form. Confirm who must sign it, where it should be delivered, whether any payment must accompany it, and when the requested coverage would become effective.
After submission, request confirmation that the statement was received and accepted for review. A sent email or fax confirmation only shows that the document was transmitted. It does not prove that coverage has been reinstated.
Keep all related correspondence together, including the signed form, proof of delivery, payment receipt, policy documents, and the insurer’s written decision.
Most importantly, do not guess about whether an event should be disclosed. Contact the insurer or a qualified insurance professional when you are uncertain.
Important Disclaimer
This printable no loss statement is a general informational template and is not legal, insurance, underwriting, or professional advice.
Insurance carrier requirements, certification wording, submission procedures, and applicable notices may vary by insurer, policy, and state.
Using this template does not guarantee policy issuance, renewal, reinstatement, backdating, retroactive coverage, claim payment, or carrier approval. Use the insurer’s required form whenever one is provided.
Do not sign a no loss statement if you are aware of a loss, accident, claim, damage, injury, complaint, demand, incident, or circumstance that could potentially result in a claim during the stated period.
False, incomplete, or misleading information may have serious legal, financial, and coverage consequences.
