ACORD 37 Fillable | Statement of No Loss

It’s the Statement of No Loss. When an insurance company cancels a policy because the premium went unpaid, the insured can try to pay the past-due amount and bring the policy back. Before the carrier agrees, it often asks the insured to sign this form. The signature certifies that nothing happened while the coverage was off: no losses, no accidents, and no circumstances that could lead to a claim.

Most carriers accept the standard ACORD statement of no loss. A few send their own version, so ask your agent which one your carrier wants.

ACORD’s own instructions point to one situation, and three things have to be true.

Premium went unpaid

The carrier canceled the policy, or the policy lapsed, because the premium didn’t arrive on time.

The insured wants it back

The former insured wants to pay the past-due premium and reinstate the coverage.

The carrier allows it

The agency’s contract with the company, or the company’s own rules, let the carrier reinstate. Some carriers won’t reinstate after a lapse of a certain length, so check before you count on it.

One page, six parts, in the order they appear.

1. 1

   Agency & Contact

   The agency that handles the policy, with a contact name, phone, fax, email, agency code, and customer ID.

2. 2

   Named Insured, Carrier & Policy

   The policyholder’s name, the insurance company and its NAIC code, and the policy number. Copy the policy number exactly as it appears on the policy, prefix and suffix symbols included.

3. 3

   Approved By

   The carrier’s underwriter or staff member who should receive the form.

4. 4

   The Certification

   One sentence the insured certifies, with two blanks: the cancellation date, and the date and time of signing. Everything between those two points is the period the statement covers.

5. 5

   Applicant’s Signature

   The named insured signs here.

6. 6

   Receipt

   A section for the agency. It records the dollar amount the producer collected, the producer’s name, a witness, and the date and time.

The certification has two blanks, and they matter more than anything else on the page. The first is the cancellation date. The statement starts at 12:01 AM that day. The second is the date and time you sign. The statement covers every hour between them. Anything before the cancellation date or after you sign falls outside it. Because the second blank marks the moment you sign, write the real date and time. Don’t leave the time empty, and don’t backdate it.

Don’t sign the form. A signature says you know of no losses, accidents, or circumstances that could lead to a claim, so signing after a known loss makes a false statement. Tell your agent what happened first. The carrier may still reinstate the policy, but it can also decline, re-underwrite the risk, or offer different terms. Some carrier versions of this form warn that a false statement can void the reinstatement.

Fill in the agency block and the receipt, and collect the past-due payment. Have the insured sign with the real date and time. Send the form to the underwriter named in the Approved By box, and keep a copy in the file. Never sign for the insured.