Affidavit Of No Loss

Insured Name __________________________ Policy Number _________________________

AFFIDAVIT OF NO LOSS

I, ____________________________________ of ____________________________________,

in the city of _____________________, Massachusetts, hereby depose and swear:

That I, or any listed operator on my insurance policy, or any person who may

be afforded coverage from my insurance policy, have not been involved in

any automobile accidents, or other losses, from the date of cancellation of

my policy, ____________ to today, the ________ day of _________________,

___________ at ________: _________ am/pm.

Signed under the pains and penalties of perjury.

_______________________________________

(Insured’s Signature)

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Parent category: Legal