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

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*