ACORD 37 (2008/01)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 37 (2008/01)
STATEMENT OF NO LOSS
ACORD 37, Statement of No Loss is used when:
* A policy issued by your agency has been cancelled, or has lapsed, because premium for
the policy was not paid in time;
* The former insured desires to pay the delinquent premium and reinstate insurance
without a lapse in coverage; and
* Your contract with the insuring company, or the company's rules, permit policy
reinstatement. (You may have to contact your company before
proceeding.)
By signing this form, the former insured certifies that there were no losses, or
circumstances that might give rise to a claim under the policy, during the period coverage
had lapsed.
This form is also a receipt for the premium payment you collect at the time the form is
signed. The form is NOT an insurance binder.
IDENTIFICATION SECTION Agency
Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address line one of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address line two of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address city name of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address state or province code of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address postal code of the producer/agency.
IDENTIFICATION SECTION Contact Name
Enter text: The name of the individual at the producer's establishment that is the primary
contact.
IDENTIFICATION SECTION Phone (A/C, No, Ext)
Enter number: The producer's contact person's phone number. If applicable, include the
area code and extension.
Universal wording updates to improve clarity and intent were made to all FIG text for this form on 01/30/2009.
ACORD 37 (2008/01)
1 of 3
Section Name
Field Name
Field and/or Section Description
Universal wording updates to improve clarity and intent were made to all FIG text for this form on 01/30/2009.
IDENTIFICATION SECTION FAX
Enter number: The fax number of the producer/agency.
IDENTIFICATION SECTION E-Mail Address
Enter text: The producer's contact person e-mail address.
IDENTIFICATION SECTION Code
Enter code: The identification code assigned to the producer (e.g. agency or brokerage
firm) by the insurer.
IDENTIFICATION SECTION Subcode
Enter code: The identification code assigned by the insurer to the sub-producer (e.g.
person) within a producer's office (e.g. agency or brokerage).
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION Named Insured
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy.
Use the actual name of the company within the group to which the policy has been issued.
This is not the insurer's group name or trade name.
IDENTIFICATION SECTION NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION Policy #
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If
required for self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION Approved By
Enter text: The company underwriter (or other company staff person) that this form should
be directed to.
IDENTIFICATION SECTION Cancellation Date
Enter date: The effective date of the cancellation or non renewal.
IDENTIFICATION SECTION Date Signed
Enter date: The date the form was signed by the named insured.
IDENTIFICATION SECTION Time Signed
Enter time: The time the form was signed by the named insured.
ACORD 37 (2008/01)
2 of 3
Section Name
Field Name
Field and/or Section Description
Universal wording updates to improve clarity and intent were made to all FIG text for this form on 01/30/2009.
IDENTIFICATION SECTION Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
RECEIPT
Amount Received
Enter amount: The amount of the premium received as a deposit.
RECEIPT
Producer
Enter text: The name of the authorized representative of the producer, agency and/or
broker that signed the form.
RECEIPT
Witness
Sign here: The signature of the witness to the form.
RECEIPT
Date
Enter date: The date the witness signed the form.
RECEIPT
Time
Enter time: The time the witness signed the form.
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
ACORD 37 (2008/01)
3 of 3