STATEMENT OF NO KNOWN CLAIMS OR LOSSES FOR PROFESSIONAL LIABILITY INSURANCE

Insured's First Name*

Insured's Last Name*

Requested Effective Date*

Month/Day/Year

Last Coverage Date or Retroactive Date*

Month/Day/Year

Email*

Policy Number

Cancel for Non-Payment

Renewal

New Business

I do hereby represent and certify to you that: to the best of my knowledge, information and belief, during the period from the last coverage date or retroactive date (indicated above) until the date of this letter, no claim or action arising out of my practice of chiropractic medicine has been asserted or brought against me, except for claims or actions previously reported to OUM or disclosed on any application submitted to OUM.

I am not aware of any actual claims or suits against me, or any incidents, facts, circumstances, acts, errors, or omissions, which could reasonably be expected to be the basis of a claim or suit against me, for professional services. I further certify that I am not aware of any incident that could reasonably be believed to result in the assertion of a claim or the filing of an action.

I understand the signing and returning of this No Known Loss form does not ensure reinstatement of my policy. Any reinstatement of coverage is subject to underwriting review and approval. A review will be conducted and I will be contacted to advise of the status of my malpractice insurance policy.*

Signature of Applicant*

Date*

Month-Day-Year