Statement of No Loss

PRODUCER INSURED'S NAME

TELEPHONE NUMBER:

COMPANY:

APPROVED BY:

POLICY #

CODE: SUBCODE:

CANCELLATION DATE DATE AND TIME SIGNED

APPLICANT'S SIGNATURE

PRODUCER

WITNESS DATE AND TIMEDATE AND TIME

$ AMOUNT RECEIVED BY:

ACORD 37 (1/96) © ACORD CORPORATION 1996

RECEIPT

I CERTIFY THAT THERE HAVE BEEN NO LOSSES, ACCIDENTS OR

CIRCUMSTANCES THAT MIGHT GIVE RISE TO A CLAIM UNDER

THE INSURANCE POLICY WHOSE NUMBER IS SHOWN ABOVE,

FROM 12:01 AM ON TO .

ACORD

STATEMENT OF NO LOSS

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