ACORD 37 Statement of No Loss Form – Fillable PDF Download
Statement of No Loss
The ACORD 37 Statement of No Loss is commonly used to certify that no claims, damages, or incidents occurred before an insurance policy is cancelled.
Form Type: Cancellation / Declaration
Edition: 2008/01
Category: Policy Administration
Purpose: Premium Refund
Download ACORD 37 Form
Free fillable PDF – Current edition
What is ACORD 37 Statement of No Loss?
ACORD 37 is a legal declaration stating that the policyholder is not aware of any losses, accidents, or circumstances that might give rise to a claim during the policy period being cancelled. This statement is required by insurance carriers before they will issue a return premium refund when a policy is cancelled mid-term.
The form serves as a critical protection mechanism for insurance companies against fraud and ensures policyholders don’t cancel policies after an incident occurs while still collecting unearned premium.
📊 When This Form is Used
ACORD Statement of No Loss form is required for mid-term policy cancellations when the policyholder requests cancellation before the policy’s natural expiration date. It is NOT needed when a policy simply expires and is not renewed.
Primary Purpose
The Statement of No Loss accomplishes several critical functions:
- Fraud Prevention: Prevents policyholders from cancelling coverage immediately after an incident occurs but before filing a claim, then collecting return premium they’re not entitled to.
- Premium Refund Authorization: Authorizes the insurance carrier to calculate and issue return premium for the unused portion of the cancelled policy period.
- Legal Documentation: Creates a binding legal record that the policyholder certified no known losses as of the cancellation date.
- Claims Prevention: If policyholder later tries to file a claim for an incident that occurred before cancellation, carrier can deny based on false certification.
🚫 Critical Legal Warning
Signing a false Statement of No Loss is insurance fraud. If you sign this form certifying no losses when you know of an incident, accident, or circumstance that could result in a claim, you commit fraud punishable by:
- Criminal prosecution (felony in most states)
- Fines $5,000 to $50,000+
- Imprisonment 1-5 years
- Policy voidance (retroactive cancellation)
- Forfeiture of all return premium
- Personal liability for covered claims
- Difficulty obtaining insurance in the future
The Certification Language
The form contains this critical certification statement:
“I CERTIFY THAT I AM NOT AWARE OF ANY LOSSES, ACCIDENTS OR CIRCUMSTANCES THAT MIGHT GIVE RISE TO A CLAIM UNDER THE INSURANCE POLICY WHOSE NUMBER IS SHOWN ABOVE, FROM 12:01 AM ON [CANCELLATION DATE] TO [DATE AND TIME SIGNED].”
What This Certification Means:
- “Not aware” – You have no knowledge of any incidents
- “Losses, accidents” – Actual events that occurred
- “Circumstances that might give rise to a claim” – Situations that could potentially become claims even if no formal claim filed yet
- “From 12:01 AM on [date]” – Covers the entire period from policy effective date through signing date
When ACORD 37 is Required
Understanding when you need this form prevents delays in receiving return premium and ensures compliance with carrier requirements.
Situations Requiring ACORD 37
Sold the Business
Business sold to new owner who will obtain their own insurance. You cancel existing policy mid-term. ACORD No Loss form required to receive pro-rata or short-rate refund of premium for remaining policy period.
Switching Insurance Carriers
Found better coverage or pricing with different carrier. Cancel current policy before expiration to start new policy. Most carriers require Acord no loss form before refunding premium for unused term.
Ceasing Operations
Going out of business, closing location, or discontinuing operations. Cancel policy mid-term. Statement of No Loss required to get return premium.
Specific Coverage No Longer Needed
Sold all vehicles (cancel auto policy), sold building (cancel property), laid off all employees (cancel workers comp). Mid-term cancellation triggers ACORD 37 requirement.
Duplicate Coverage Discovered
Realize you have overlapping policies insuring same property or risk. Cancel duplicate policy mid-term. Carrier requires no loss acord form for refund.
Premium Financing Payoff
Paid off premium finance agreement early and want to cancel financed policy. Finance company and carrier require ACORD 37 to process early termination refund.
When Statement Of No Loss is NOT Required
Policy Expires Naturally
Policy reaches end of term and not renewed – no statement of no loss needed
Carrier Cancels Policy
Insurance company initiates cancellation for non-payment or underwriting reasons
Flat Cancellation
Policy cancelled on effective date with no coverage period elapsed
Policy Renewal
Moving from one policy term to next with same carrier
Timing Considerations
📅 When to Sign ACORD 37
Sign statement of no loss on or after the desired cancellation date, NEVER before.
Correct Timeline:
- Decide to cancel policy effective February 15, 2026
- Wait until February 15, 2026 arrives
- On February 15 or later, sign ACORD certifying no losses from policy inception through today
- Submit to carrier for processing
Why This Matters: You’re certifying no losses through the date/time you sign. You can’t certify about future dates you haven’t reached yet.
How to Complete ACORD 37 Fillable PDF Form
Before You Sign
🛑 STOP – Answer These Questions FIRST
DO NOT sign ACORD 37 PDF if the answer to ANY of these questions is YES:
- Has any accident, incident, or loss occurred during the policy period?
- Has anyone been injured on your premises or by your operations?
- Has any property damage occurred that you or your business caused?
- Are there any pending lawsuits, claims, or demands against you?
- Are there any customer complaints that could turn into claims?
- Are there any employment disputes or EEOC complaints?
- Are you aware of ANY circumstances that might result in a claim?
- Has ANYTHING happened that your insurance might need to cover?
If YES to any question: DO NOT sign. Contact your insurance agent immediately to discuss your situation.
Step 1: Verify Cancellation is Appropriate
- Confirm you want to cancel: This is final once processed
- Have replacement coverage: If switching carriers, new policy should be in force BEFORE cancelling old one
- Understand refund calculation: Pro-rata vs short-rate (explained below)
- Check for cancellation fees: Some policies charge administrative fees
Step 2: Determine Cancellation Date
- Immediate cancellation: Cancel today (most common)
- Future date: Cancel on specific future date (but cannot sign ACORD 37 until that date arrives)
- Backdated cancellation: Some carriers allow cancelling effective a past date IF you can certify no losses occurred – risky and uncommon
Step 3: Download ACORD 37 Form
- Download from this website
- Request from your insurance agent (they should provide)
- Download from carrier website (some carriers have their own version)
Step 4: Complete Agency Information (5 minutes)
Your insurance agent typically completes this section, but if you’re filling out the form yourself:
- Enter agency name and full address
- Agent contact name
- Phone, fax, email
- Any internal codes/customer IDs
Step 5: Complete Policy Information (5 minutes)
- Named Insured: Your legal name EXACTLY as shown on policy
- Carrier: Full insurance company name from policy
- NAIC Code: From policy declarations page
- Policy Number: CAREFULLY copy from declarations page – verify twice
- Approved By: Leave blank (carrier completes)
Step 6: Complete Certification Statement (5 minutes)
Cancellation Date:
- Enter the date you want coverage to end: MM/DD/YYYY
- This MUST be today or a past date (cannot be future)
- Example: 02/15/2026
Date and Time Signed:
- Today’s date and current time
- Must be on or after cancellation date
- Example: 02/15/2026 at 2:45 PM
Step 7: Sign the Form
Signature Requirements:
- Must be signed by authorized person: owner, officer, partner, authorized manager
- Sign your actual signature (not typed name)
- Date and time when signed
- Keep a copy for your records before submitting
Step 8: Submit to Insurance Agent/Carrier
- Scan and email to agent (most common)
- Fax to agent or carrier
- Mail original (if required – delays processing)
- Hand deliver to agent
Step 9: Follow Up on Refund Processing
- Days 1-5: Agent submits to carrier
- Days 5-15: Carrier processes cancellation and calculates refund
- Days 15-30: Refund check issued
- Days 30-45: Check received in mail
If no refund after 45 days: Contact agent to investigate delay.
Understanding Return Premium Calculations
When you cancel a policy mid-term, you’re entitled to a refund of unearned premium. However, HOW MUCH you get back depends on the cancellation method.
Two Types of Cancellation
Pro-Rata Cancellation
Most Favorable to Policyholder
Calculation: You get back exactly the portion of premium for unused time. No penalties.
Example:
- Annual Premium: $1,200
- Policy Period: 12 months
- Cancel after: 3 months
- Unused time: 9 months (75%)
Refund: $900
When Used: Carrier-initiated cancellations, policy sold with business, some states mandate pro-rata for certain cancellations
Short-Rate Cancellation
Penalizes Policyholder
Calculation: Carrier keeps 10-20% penalty plus actual earned premium. You get back less than pro-rata.
Example:
- Annual Premium: $1,200
- Policy Period: 12 months
- Cancel after: 3 months
- Pro-rata refund would be: $900
- Short-rate penalty: 10% = $90
Actual Refund: $810
When Used: Policyholder-initiated mid-term cancellations (most common)
Short-Rate Penalty Tables
|
Months in Force |
Pro-Rata Earned |
Short-Rate Earned |
Penalty |
|---|---|---|---|
|
1 month |
8% |
12% |
+4% |
|
2 months |
17% |
22% |
+5% |
|
3 months |
25% |
32% |
+7% |
|
4 months |
33% |
41% |
+8% |
|
6 months |
50% |
60% |
+10% |
|
9 months |
75% |
83% |
+8% |
|
10 months |
83% |
90% |
+7% |
Minimum Earned Premium
Many policies have a “minimum earned premium” clause:
- Carrier keeps minimum amount regardless of cancellation timing
- Typically $250-$1,000 depending on policy type
- Example: Cancel $600 annual policy after 1 week, minimum earned is $250 – you only get $350 back
Additional Fees and Charges
Be aware of these potential deductions from return premium:
- Policy Fee: $50-200 administrative charge (non-refundable)
- Inspection Fee: If property was inspected, fee retained
- Premium Finance Charges: If premium was financed, finance company keeps their interest/fees
- Installment Fees: If paying monthly, carrier may keep installment charges
Download ACORD 37 – Statement of No Loss Form
Use this official PDF to confirm no losses and complete your insurance cancellation properly.
Frequently Asked Questions
What if I sign ACORD 37 and later discover an incident occurred before cancellation?
Contact your insurance agent IMMEDIATELY. If claim hasn’t been filed yet, agent may be able to withdraw cancellation request or reinstate policy. If you unknowingly signed false statement (genuinely didn’t know about incident), explain circumstances to carrier – they may still honor coverage depending on situation. But you MUST disclose as soon as you discover the error.
Can I cancel the cancellation after signing ACORD 37?
Maybe – depends on carrier and whether cancellation has been processed. If you change your mind within a few days, contact agent immediately. Some carriers allow withdrawal of cancellation request. After cancellation is processed and refund issued, reinstating coverage requires new application and underwriting.
Do I get the full premium back?
No. You only get back premium for the unused portion of the policy period. Most policyholder-initiated cancellations are “short-rate” meaning you pay 10-20% penalty. Carrier also deducts policy fees, minimum earned premium, and any other charges. Your refund is typically 60-80% of what you’d expect on pro-rata basis.
How long until I receive my refund?
Typically 30-60 days from when carrier receives properly completed ACORD form. Timeline: Agent submits form (1-5 days), carrier processes (5-15 days), carrier issues check (5-10 days), mail delivery (5-10 days). If no refund after 60 days, contact agent to investigate.
What if I have a claim pending when I want to cancel?
YOU CANNOT HONESTLY SIGN ACORD 37. Pending claims are exactly what the form asks about. Carrier will not cancel policy mid-term with open claims. Wait until claim is completely resolved and closed, then you can cancel for future period. Attempting to cancel while hiding pending claim is insurance fraud.
Can I backdate the cancellation?
Rarely and risky. Some carriers allow backdating IF you can honestly certify no losses occurred during the backdated period. For example, cancel on March 15 but make it effective March 1 – you’d need to certify no losses March 1-15. Most agents advise against backdating due to fraud risk. Better to cancel effective today.
Do I need Statement of No Loss if the carrier is cancelling my policy?
NO. ACORD 37 is only for policyholder-initiated cancellations. If carrier cancels for non-payment, underwriting reasons, or non-renewal, you do NOT need Statement of No Loss. However, you won’t get return premium if cancelled for non-payment.
Can my agent sign this form for me?
NO. Only the named insured or authorized representative of the company can sign. Your agent cannot sign on your behalf. This is YOUR legal certification and must be signed by you or your authorized officer.
If I sign ACORD 37 and incident occurred, what are the actual penalties?
Varies by state but commonly: (1) Felony insurance fraud charges, (2) Fines $5,000-$50,000+, (3) Imprisonment 1-5 years, (4) Policy voidance retroactive to inception (all claims denied), (5) Forfeiture of return premium, (6) Civil lawsuit from carrier for damages, (7) Difficulty obtaining insurance in future (fraud record follows you).
Does this form affect future claims under new policy?
No. this form only addresses the cancelled policy period. Claims arising from new incidents after cancellation are covered by your new policy. However, if you falsely certified no losses on old policy and incident actually occurred before cancellation, that claim is NOT covered by either policy – old policy denied for fraud, new policy excludes prior acts.
Is ACORD 37 required in all states?
While acord no loss form is industry-standard, state requirements vary. Some states mandate return premium on pro-rata basis without requiring statement. However, most carriers require this form regardless of state law as protection against fraud. Check with your agent for state-specific requirements.