InsertInsuredName
InsertInsuredAddress
“NO KNOWN LOSS” CERTIFICATION
The undersigned, representing that he/she has authority to certify and make representations as the Insured
and on behalf of the Insured, as a condition precedent to the Insurer’s issuing or reinstating the policy/policies
listed below without a lapse in coverage, hereby certifies and warrants that between the beginning of the lapse
and the date of the insured’s signature below, that no losses, occurrences, accidents, or other circumstances or
events occurred or were alleged to have occurred, for which a claim for coverage or defense could be made
under the terms of the Policy as set forth therein. The undersigned understands that the insurer is relying solely
upon this Certification of NO KNOWN LOSS as an inducement to bind the issuance or reinstatement of the
policy/policies without a lapse in coverage.
The undersigned further states and understands that if any such event as described above occurred, or was
alleged to have occurred, during the period described above and the undersigned is found to have had
knowledge of such an event or any allegations of such events the submission of this Certification by the
undersigned constitutes a MATERIAL MISREPRESENTATION and may, subject to applicable law, result in the
IMMEDIATE RESCISSION OF THE POLICY, the denial of claims, and defense, if any, and the possible imposition
of civil and/or criminal penalties. The undersigned further understands that if the insurer becomes obligated to
make any payment (or incurs any expenses) under the policy for a loss, occurrence, accident, or other
circumstances or events occurring between the beginning of the lapse and the date of the insured’s signature
below, the undersigned shall reimburse insurer for such payment and any expenses (including reasonable
attorney fees) to the fullest extent allowed by law. The insurer reserves all rights to assess any losses,
occurrences, accidents, or other circumstances or events that occur within the period described above.
The undersigned agent further certifies that prior to execution of this document, the insured location was
inspected, all relevant documents reviewed, and all relevant individuals consulted with, and no loss was evident
at the time of such inspection, review and consultation.
The undersigned, by signing this certification, represents that he/she has authority to make this certification
and these representations on behalf of the Insured with respect to the Policy.
BeginningDateofLapseinCoverage:
Agent Signature: Title: ______
Print Name: ______ Date:
Insured Signature: ___________________________________
Print Name: ________________________________________ Date: _________________________________
Policyholder Name: _ __________________
(Proposed) GUARD Homeowners Policy Number: ______________________________
(Proposed) Effective Date:_____________________
FRAUD WARNING
Any person who knowingly and with intent to defraud any insurance company or other person files
an application for insurance or statement of claim containing any materially false information or
conceals for the purpose of misleading information concerning any fact material thereto commits a
fraudulent act, which is a crime and subjects such a person to criminal and civil penalties.
Ed. 5-01-20
Please print this document on the insured's letterhead. (This
reminder will not print on your letter.)
