Get the free surplus lines disclosure and acknowledgement form

DWELLING FIRE APPLICATION AGENCY PHONE (A/C, No, Ext): FAX (A/C, No): APPLICANT'S NAME AND MAILING ADDRESS (Include county & ZIP+4) NAIL CODE DATE (MM/DD/YYY) FACILITY CODE POLICY # DATE AT CURE RES

How to fill out surplus lines disclosure and

How to fill out surplus lines disclosure:

1. Obtain a surplus lines disclosure form from your insurance agent or company.
2. Fill out the top section of the form with your name, address, and contact information.
3. Provide information about the insured party, such as their name, address, and contact information.
4. Indicate the policy number and effective dates of the surplus lines coverage.
5. Specify the type of risk being covered, such as property, liability, or professional indemnity.
6. Describe the coverage being provided in detail, including any policy limits or exclusions.
7. Sign and date the disclosure form, indicating your agreement to the terms and conditions.

Who needs surplus lines disclosure:

1. Insurance agents: Agents must provide surplus lines disclosure to their clients when placing coverage in the surplus lines market.
2. Insured parties: Any individual or business obtaining insurance coverage from a surplus lines insurer may be required to sign a surplus lines disclosure form. This ensures they understand that the policy is being placed through a non-admitted insurer and may have different regulations and consumer protections compared to admitted insurers.
3. Regulators: Surplus lines disclosure is necessary for regulatory purposes to ensure compliance with state insurance laws and regulations.

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What is surplus lines disclosure?

Surplus lines disclosure refers to the requirement for insurance brokers to disclose certain information related to the placement of insurance coverage with non-admitted insurers, also known as surplus lines insurers.

Who is required to file surplus lines disclosure?

Insurance brokers or agents who place insurance coverage with non-admitted insurers are required to file surplus lines disclosure.

How to fill out surplus lines disclosure?

Surplus lines disclosure forms can typically be obtained from the insurance regulatory authority in the respective jurisdiction. The form must then be completed with the required information, which may include details about the insured, the insurance coverage placed, the non-admitted insurer, and any applicable premiums or fees.

What is the purpose of surplus lines disclosure?

The purpose of surplus lines disclosure is to ensure transparency and accountability in the placement of insurance coverage with non-admitted insurers. It helps regulators monitor the surplus lines market and protects policyholders by ensuring compliance with applicable laws and regulations.

What information must be reported on surplus lines disclosure?

The specific information required to be reported on surplus lines disclosure forms may vary by jurisdiction. However, it commonly includes details about the insured, the insurance coverage placed, the non-admitted insurer, and any applicable premiums or fees.