Chubb in the US
Representation of No Known Losses. Date: Named Insured: Policy Number: Proposed Effective Date of Coverage: The undersigned declares that from , 20 through , 20, no claims have been made, and that the undersigned knows of no losses, and no threats of any claims have been made, against any person or entity who or which could be covered under the proposed insurance policy referenced above (the ... ................
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