Statement of No Loss

I, ___________________________________________, affirm that no losses, claims, or events likely to result in a loss or claim have occurred in relation to my property previously insured under policy number____________________________with Universal Property and Casualty Insurance Company (UPCIC). On the basis of this statement, I request that UPCIC reinstate my insurance policy.

I understand that my representation is an important part of UPCIC's decision to reinstate my policy, and that UPCIC intends to rely upon the truthfulness of this representation in connection with its decision. I further understand that an incorrect statement or omission of fact relating to my request for reinstatement may prevent recovery under the policy. This "statement of no loss" pertains to the period of time beginning with the expiration of my policy through the date I signed this statement.