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Statement of No Loss Template

Confirm to an insurer that no accidents or losses happened during a lapse, so a policy can be reinstated.

Use this free template Free account, so you can save and send it. Log in

SimpleFullPlain-English Summary

Full: detailed and comprehensive, with optional clauses you can switch on.

This template is not legal advice; consult a licensed attorney in your state. Insurance is regulated state by state: some states restrict assignments of benefits and direction-to-pay forms, require specific claim or cancellation notices, or require a licensed agent or adjuster. Your insurer may also require its own form.
E-Sign Auto is not a law firm and does not provide legal advice.

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1. Parties2. Details

Parties

Signing order: Policyholder โ†’ Insurer / Agent (acknowledgment). Each signer is invited after the previous one signs.

1. Policyholder
2. Insurer / Agent (acknowledgment)

Signature, date and name fields are added for every signer automatically.

Details

Use this free template (sign up)

Signature, initials (every page) and date fields are placed for each party. You can review and adjust them before sending.

Live preview

How to use this Statement of No Loss template

  1. Answer the guided questions. Your name and company fill in automatically from your profile.
  2. Pick the governing state and complete the [STATE-SPECIFIC] blanks. Switch optional clauses on or off.
  3. Check the live preview, then create the document. Signature, initial and date fields are placed for each party.
  4. Review the fields and send. Each party signs in order, and everyone gets the signed PDF.

Frequently asked questions

Is this Statement of No Loss template free?

Yes. You can fill it in, download it and send it for electronic signature with a free E-Sign Auto account.

Is an electronically signed Statement of No Loss legally binding?

In the U.S., the federal ESIGN Act and state UETA laws generally give e-signatures the same effect as handwritten ones. Check your state's rules.

Does this template work in my state?

It is a generic, state-neutral starting point. Pick your governing state and complete every blank marked [STATE-SPECIFIC]. This template is not legal advice; consult a licensed attorney in your state.

Who signs, and in what order?

Policyholder, then Insurer / Agent (acknowledgment). Each signer gets a secure link in that order, with signature, initial and date fields already placed.