"Statement of No Loss Form" - Alabama

Statement of No Loss Form is a legal document that was released by the Alabama Department of Agriculture and Industries - a government authority operating within Alabama.

Form Details:

  • The latest edition currently provided by the Alabama Department of Agriculture and Industries;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Alabama Department of Agriculture and Industries.

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Download "Statement of No Loss Form" - Alabama

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Print Form
STATEMENT OF NO LOSS
PRODUCER'S NAME, ADDRESS & PHONE NUMBER:
OLD POLICY NUMBER:
Include Area Code
(
)
INSURED'S NAME, ADDRESS & PHONE NUMBER:
NEW POLICY NUMBER:
(
)
Include Area Code
INSURANCE COMPANY'S NAME:
APPROVED BY (Underwriter):
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
Date Policy Reinstated
Cancellation Date
Applicant's Signature
Name of Applicant's Company
RECEIPT
RECEIVED BY:
Producer
Date
Notary Public
Affix Notary
Seal Here
My Commission Expires
Print Form
STATEMENT OF NO LOSS
PRODUCER'S NAME, ADDRESS & PHONE NUMBER:
OLD POLICY NUMBER:
Include Area Code
(
)
INSURED'S NAME, ADDRESS & PHONE NUMBER:
NEW POLICY NUMBER:
(
)
Include Area Code
INSURANCE COMPANY'S NAME:
APPROVED BY (Underwriter):
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
Date Policy Reinstated
Cancellation Date
Applicant's Signature
Name of Applicant's Company
RECEIPT
RECEIVED BY:
Producer
Date
Notary Public
Affix Notary
Seal Here
My Commission Expires