Fill - Free fillable - NO KNOWN LOSS STATEMENT PDF form

NOKNOWNLOSSSTATEMENT

DATE:____________________________

Insured:__________________________ __________________________________________________

Locationforwhichcoverageisrequested:_________________________________________________

_________________________________________________

I attest that there has not been more than one flood loss within the past five years or any single flood

loss to the structure of $250,000 or greater.

Thereisnoun‐repairedorstructuraldamagetothepropertywherecoverageisrequestedduetoflood.

Additionally, I agree to notify you in the event a loss occurs between now and the premium receipt date.

I understand that this policy is not intended to cover losses prior to the inception date of the policy or

the premium receipt date, whichever is later.

________________________________ ____________________________

InsuredSignature Date

FraudWarning

Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherpersonfile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

insuranceact,whichisacrimeandsubjectsuchapersontocriminalandcivilpenalties.

Fill Online, Printable, Fillable, Blank - NO KNOWN LOSS STATEMENT Form