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Insurance - 2 - 13806 Coit Rd, Cleveland, OH 44110.pdf

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REPRESENTATION OF NO KNOWN LOSS Email to risksecure@oscis.com or include with Request for Reinstatement Policy Number: 5702862 Proposed Effective Date of Date: 09.18/2025 01/24/2025- 09/18/2025 Named Insured: Lofty Holding 13806 Coit Rd DAO Coverage: Property Address: LLC 13806 Coit Rd, Cleveland, OH 44110 0,43 The undersigned declares that no claims have been made, and that the undersigned knows of no losses or events likely to result in a loss or claim have occurred in relation to my property

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REPRESENTATION OF NO
KNOWN LOSS Email to risksecure@oscis.com or
include with Request for Reinstatement
Policy Number: 5702862
Proposed Effective Date of
Date: 09.18/2025

01/24/2025- 09/18/2025

Named Insured: Lofty

Holding 13806 Coit Rd DAO Coverage: Property Address:
LLC
13806 Coit Rd, Cleveland,
OH 44110

0,43

The undersigned declares that no claims have been made, and that the undersigned knows of no losses or events likely to result
in a loss or claim have occurred in relation to my property which could be covered under the proposed insurance policy
referenced above (the “Policy”), and no information has been provided to the knowledge of the undersigned on any loss that could
be covered under the Policy.
The undersigned understands that their representation is an important part of the decision to insure their property and that the
proposed insurance company intends to rely upon the truthfulness of this representation in connection with its decision. The
undersigned further understands that an incorrect statement or omission of fact relating to this representation may prevent
recovery under the Policy.
To the extent that the undersigned does have knowledge or responsibility, attach complete details of that matter to this letter.
This representation must be signed by the Named Insured or a representative duly authorized by the Named Insured. The
undersigned hereby affirms that he or she is authorized to sign on behalf of the named insured.
After diligent inquiry, I acknowledge that I have read this statement, and it is true and accurate.

Insured Signature:
Print Name:
Title:
Date: