Statement of No Loss
I, [Customer Name], state that neither I nor any other person covered by this policy has had a claim or loss or been involved in an accident
since the cancellation or expiration of the policy (otherwise known as the "no loss period") wherein this policy, including any and all
coverages endorsed upon or made part of the policy may apply.
In addition, if this reinstatement is for a personal or commercial auto, motorcycle, or RV policy, I certify that I have disclosed the current
garaging location and use of all insured vehicles including if any such vehicle is used to deliver food or goods, to transport people for
compensation, or for any other business purpose. I have also disclosed household members who are age 14 or older, and all persons who
regularly drive any vehicle insured under this policy.
I understand that this insurance company is relying solely upon this Statement of No Loss all of which is material, as an inducement to
reinstate my policy with no lapse in coverage. I further understand that if a claim, loss, or accident has occurred during the no loss period, or
if I failed to disclose the current garaging location and primary use of all vehicles insured under this policy, all persons who regularly drive
these vehicles, and all members of my household who are age 14 or older, the reinstatement is null and void, my policy remains cancelled
and no insurance coverage shall be provided.
I agree that if my check or other payment for this reinstatement is not honored for any reason, the reinstatement is null and void and no
coverage shall exist under this policy. I agree to pay a reinstatement fee and late fee (if applicable) in addition to the premium required to
reinstate my policy. My payment will be applied first to the reinstatement and late fee and the remainder to the premium.
It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the
company. Penalties include imprisonment, fines, and denial of insurance benefits.
