The undersigned, as a condition precedent to reinstating the policy listed below without a lapse of coverage, hereby states that there were no losses, occurrences, accidents, or other events for which a claim for coverage could be made between the dates listed below. The undersigned understands that KEMI is relying solely upon this No Loss Certification as an inducement to bind the reinstatement of the policy without a lapse in coverage.

The undersigned further states and understands that if any loss, occurrence, accident, or other event for which a claim for coverage is made occurring between the dates listed below, the submission of the No Loss Certification constitutes a material misrepresentation and will result in either a cancellation or rescission of the policy, as permitted by law, and may result in the imposition of civil and/or criminal penalties. The undersigned further understands that if KEMI becomes obligated to make any payment under the policy for a loss, occurrence, accident, or other event occurring between the dates listed below, KEMI will seek reimbursement for such payment from the undersigned to the fullest extent allowed by law.

The undersigned, by signing this No Loss Certification, represents that he/she has the authority to make these representations with respect to the policy.