Get the free Surplus Lines Affidavit of Originating Agent

Property & Casualty 2100 Stella Court Columbus, OH 432151067 (614) 6442658 (614) 7281280 www.ohioinsurance.gov Ohio Department of Insurance Bob Taft Governor Ann Women Benjamin Director Surplus Lines

How to fill out surplus lines affidavit of

How to fill out surplus lines affidavit of:

1. Obtain the surplus lines affidavit form from your state insurance department or the appropriate regulatory agency.
2. Fill out the top section of the form with your personal information, including your name, address, and contact details.
3. Provide information about the insurance policy for which you are submitting the surplus lines affidavit. Include the policy number, effective date, and any endorsements or riders.
4. Indicate the type of coverage being provided by the policy, such as property, liability, or professional liability.
5. Specify the insured entity or individual who is covered by the policy. Include their name, address, and any relevant identification numbers.
6. Provide details about the insurance producer or broker involved in procuring the surplus lines policy. Include their name, contact information, and license number.
7. Include the name and address of the surplus lines insurer or underwriter who is providing the coverage.
8. Indicate the premium amount for the policy and any applicable fees or taxes.
9. Sign and date the surplus lines affidavit, certifying that the information provided is true and accurate to the best of your knowledge.

Who needs surplus lines affidavit of:

1. Insurance brokers or producers who are involved in procuring surplus lines insurance policies.
2. Insured entities or individuals who are obtaining coverage through the surplus lines market.
3. Regulatory agencies or state insurance departments that require the submission of surplus lines affidavits to monitor and regulate the surplus lines market.

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What is surplus lines affidavit of?

Surplus lines affidavit is a form used to report and document surplus lines insurance transactions.

Who is required to file surplus lines affidavit of?

Insurance companies and individuals who write or place surplus lines insurance are required to file the surplus lines affidavit.

How to fill out surplus lines affidavit of?

The surplus lines affidavit should be filled out accurately and completely, including all required information about the surplus lines transactions.

What is the purpose of surplus lines affidavit of?

The purpose of surplus lines affidavit is to ensure compliance with state insurance regulations and to provide documentation of surplus lines insurance transactions.

What information must be reported on surplus lines affidavit of?

The surplus lines affidavit must include information such as insured's name, policy number, premium amount, and details of the insurance coverage.