LOSS WARRANTY LETTER  

Named Insured: 									

During the last five (5) years, I warrant that with respect to the membership / insurance being applied 

for :  ______________________________________ 
                                             COMPANY 
1	Has not sustained a loss; 
2	Has not had a claim made against it;
3	Has not been denied coverage or has not had coverage canceled by an insurance company; and 
4	Has no knowledge or reason to anticipate a claim or loss. 

If COMPANY is less than five (5) years old; the above referenced warranty applies to work performed through all my prior business entities whether as an owner or an employee. 
I understand that this warranty will be incorporated into the membership contract and verify that the above information is true and accurate. 

___________________________________        __________/______________/__________ 
COMPANY                                                                                  DATE 

___________________________________        __________/______________/__________
SIGNATURE OF OFFICER, PRINCIPAL, OR OWNER PRINTED NAME/TITLE 
WARRANTY: The purpose of this no loss letter is to assist in the underwriting process; information contained herein is specifically relied upon in determination of insurability. The above signed therefore, warrants that the information contained herein is true and accurate to the best of his/her knowledge, information and belief. This no loss letter shall be the basis of any insurance that may be issued and will be a part of such policy. It is understood that any misrepresentation or omission shall constitute grounds for immediate cancellation of coverage and denial of claims, if any. It is further understood that the applicant and/or affiliated company is under a continuing obligation to immediately notify his/her underwriter through his/her broker of any material alteration of the information given.