Commercial Auto No Insurance

***** (********)

REINSTATEMENT REQUEST

STATEMENT OF NO LOSS

I state that neither I nor any other person covered by this policy has had a claim or loss or been involved in an accident since the cancellation or expiration of the policy (otherwise known as the “no loss period") wherein this policy, including any and all coverages endorsed upon or made part of the policy may apply. In addition, if this reinstatement is for a personal or commercial auto, motorcycle, or RV policy, I certify that I have disclosed the current garaging location and primary use of all vehicles, all household members who are age 14 or older, and all persons who regularly drive any vehicle insured under this policy.

I understand that this insurance company is relying solely upon this Statement of No Loss all of which is material, as an inducement to reinstate my policy with no lapse in coverage. I further understand that if a claim, loss, or accident has occurred during the no loss period, or if I failed to disclose the current garaging location and primary use of all vehicles insured under this policy, all persons who regularly drive these vehicles, and all members of my household who are age 14 or older, the reinstatement is null and void, my policy remains cancelled and no insurance coverage shall be provided. I agree that if my check or other payment for this reinstatement is not honored for any reason, the reinstatement is null and void and no coverage shall exist under this policy. I agree to pay a reinstatement fee and late fee (if applicable) in addition to the premium required to reinstate my policy. My payment will be applied first to the reinstatement and late fee and the remainder to the premium. It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. Producer Name: Providence Insurance Agency Producer Number: 173734 Policy Number: 201-***-**** Today’s Date: 2/2/2024 at 4:12 PM Policy Term: 8/11/2023 - 2/11/2024 Cancellation/Expiration Date: 2/1/2024 at 12:01 AM Producer’s Signature:

Named Insured: Brianna Dunn

Named Insured’s Signature:

If Named Insured is a Corporation, Officer Signature: Title

Payment Itemization:

Total Amount Required to Reinstate: $ 204.18

NSF Check Fee: $ 0

*fees included in Total Amount Required to Reinstate Retain a signed copy in agency file.

0000003989413100010398894530004282002030019000010001 Electronically Signed 2024-02-02 21:45:15 UTC - 166.196.110.36 Brianna Nintex AssureSign® C. 95972f92-Dunn d170-435e-b63f-b10a01618267

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