Statement of No Loss Smart PDF

Note: Complete this Statement of No Loss Form in order to bridge the data and pre-fill the pdf copy. After submission check your email for a completed copy.

Completed by *

Must be full name of the Account Manager

Agency Name *

For Edit Submission

Date (for mapping FID-00) *

Date

Agency Info:

Enter the Agency Name (DBA) *

Enter the Agency Address *

	Address
Street
City
State
Zip

Enter the Agency Phone Number *

Agency Street Address

Agency City Address

Agency State Address

Agency Zip Address

Enter the Agency Fax Number *

Enter the Agency E-mail *

Client Info:

Is the Insured a legal entity such as a LLC or Corporation or are they Individual people/sole proprietor *

Note: All the names will show on the evidence in the named insured area (box)

What is the name of the Business entity. This must match 100% exactly as it appears on the policy *

IMPORTANT: This must match 100% exactly as it appears on the policy declarations

How many named insured will there be in the policy, therefore showing on the COL. (This must match the Policy) *

Note: All the names will show on the evidence in the named insured area (box)

What is the name of the 1st Named Insured *