Great Lakes Mutual

Policy Services Forms

All form fields must be completed except where noted. Incomplete form fields will not allow the form to be submitted to Great Lakes Mutual Insurance.

Statement of No Loss

Policy/Agency Information

Policy Number

Agency Name  (optional)

Agency Code (optional)

Insured Information

First Name

 

Last Name

Property Address

Property Address Line 2 (optional)

City

Zip Code

Phone Number (required for call back)

Email Address

Cancellation Information

AS THE NAMED INSURED, BY CHECKING THIS BOX, I CERTIFY THAT THERE HAVE BEEN NO 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

(Date of Cancellation)

TO

(date and time submitted)

 

Verification Code

Retype Code