ACORD 37 Instructions

Section Name Field Name Field and/or Section Description
TITLE ACORD 37 (2008/01) Statement of No Loss Use ACORD 37 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 they are not aware of any 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 Agency's name and address.
IDENTIFICATION SECTION Contact Name Indicate the name of the contact within the agency.
IDENTIFICATION SECTION Phone No. Producer's telephone number. (Include area code and extension if applicable)
IDENTIFICATION SECTION Fax No. Producer's fax number. (Include area code)
IDENTIFICATION SECTION E-Mail Address Producer's e-mail address.
IDENTIFICATION SECTION Code Identification code assigned to the agency or brokerage firm by the insurance company receiving this form.
IDENTIFICATION SECTION Sub Code If the agency or brokerage uses a sub-code identification system with the company, enter the appropriate code.
IDENTIFICATION SECTION Agency Customer ID Customer's identification number assigned by the agency or brokerage.
IDENTIFICATION SECTION Named Insured Full name of the named insured(s) as it appears on the policy. The First Named Insured is given certain rights and responsibilities by the policy contract language. If more than one insured is named, be sure the one intended to receive these rights and responsibilities is named first and any additional insureds identified as such. If joint ownership, the name used may include both names (e.g., John and Mary Smith).
IDENTIFICATION SECTION Carrier Name of the applicable insurance company. Do not use group names; use the actual name of the company within the group that issued the policy.
IDENTIFICATION SECTION NAIC Code The identification code assigned to the company by the NAIC.
IDENTIFICATION SECTION Policy Number The number assigned by the insurance company for the policy.
IDENTIFICATION SECTION Approved By Name of the company underwriter or other company staff person who approved the resumption of coverage.
CERTIFICATION Cancellation Date Indicate the date the policy was cancelled (MM/DD/YYYY).
CERTIFICATION Date and Time Signed Indicate the date the form was signed (MM/DD/YYYY). Indicate the time the form was signed (e.g., 10:00 a.m.).
CERTIFICATION Applicant's Signature Applicant must sign the form.
RECEIPT Amount Received Indicate the amount of premium received.
RECEIPT Producer Indicate the full name of the producer.
RECEIPT Witness Signature of the witness.
RECEIPT Date and Time Signed Indicate the date the form was signed by the witness (MM/DD/YYYY). Indicate the time the form was signed (e.g., 10:00 a.m.) by the witness.
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