Get the free SURPLUS LINES DISCLAIMER STATEMENT - nai1982com

NAMED INSURED POLICY # SURPLUS LINES DISCLAIMER STATEMENT The undersigned insured hereby acknowledges: A. I understand the insurance coverage provided by this policy is written by a nonlicensed insurer

How to fill out surplus lines disclaimer statement

How to fill out surplus lines disclaimer statement:

1. Begin by including a clear and concise heading that states "Surplus Lines Disclaimer Statement".
2. Provide the name and contact information of the insurance agency or individual filling out the disclaimer statement.
3. Include the name and contact information of the insured party or the party on whose behalf the insurance is being placed.
4. Clearly state the date on which the surplus lines disclaimer statement is being filled out.
5. Provide a brief description of the insured risk, including the type of coverage required and any specific details that may be relevant.
6. State the reason why the insurance sought cannot be obtained from admitted insurance carriers in the state.
7. Include a disclaimer statement that highlights the risks associated with surplus lines insurance and the potential limitations of coverage.
8. Specify the name and contact information of the surplus lines broker responsible for procuring the insurance.
9. Sign and date the surplus lines disclaimer statement, ensuring that all relevant parties have also signed if necessary.

Who needs surplus lines disclaimer statement:

1. Insurance agents or brokers who are placing coverage with non-admitted insurance carriers.
2. Businesses or individuals seeking insurance coverage that is not offered by admitted insurance carriers in their state.
3. Insured parties or their representatives who are aware of the risks associated with surplus lines insurance and agree to proceed with such coverage.

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What is surplus lines disclaimer statement?

The surplus lines disclaimer statement is a legal document that acknowledges the policy is not being procured from a licensed insurance carrier.

Who is required to file surplus lines disclaimer statement?

Individuals or businesses who are procuring insurance coverage from a non-admitted or surplus lines carrier are required to file a surplus lines disclaimer statement.

How to fill out surplus lines disclaimer statement?

The surplus lines disclaimer statement can typically be filled out online through the state's insurance department website or by submitting a physical form provided by the department.

What is the purpose of surplus lines disclaimer statement?

The purpose of the surplus lines disclaimer statement is to inform the insured that the policy is being issued by a non-admitted insurer and that certain protections provided by licensed carriers may not apply.

What information must be reported on surplus lines disclaimer statement?

The surplus lines disclaimer statement usually requires information such as the policyholder's name, address, policy details, the name of the non-admitted insurer, and acknowledgement of the risks associated with non-admitted carriers.