Get the free Surplus Lines Lincensee Affidavit for Purchasing Groups Form 440-3928 rev 1211 DCBS ...
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Department of Consumer and Business Services Insurance Division 4 P.O. Box 14480, Salem, OR 973090405 Phone: 5039477982, Fax: 5033784351 350 Winter St. NE, 3rd floor, Salem, Oregon 973013883 insurance.Oregon.gov
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How to fill out surplus lines lincensee affidavit
How to Fill Out Surplus Lines Licensee Affidavit:
01
Obtain the correct affidavit form from the appropriate licensing authority. This form is usually available on their website or can be requested via mail or in person.
02
Carefully read through all the instructions provided on the affidavit form. Make sure you understand the requirements and the information you need to provide.
03
Begin by filling in your personal information such as your full name, contact details, and your current address.
04
Provide your license information, including the type of license you hold and its expiration date. If you have more than one license, ensure you provide the details for the license relevant to the surplus lines business.
05
If you are representing an agency or brokerage, include the business name, address, and contact information. Also, mention the surplus lines license number for the agency or brokerage.
06
Indicate if you have any active nonadmitted insurance policies and provide details if applicable. This includes listing the insurer, policy number, and date these policies became effective.
07
Sign and date the affidavit form, certifying that the information provided is accurate to the best of your knowledge.
08
Depending on the requirements of the licensing authority, you may need to attach supporting documents. These can include proof of active nonadmitted insurance policies, proof of agency or brokerage license, or any other necessary documentation.
09
Keep a copy of the completed affidavit for your records before submitting it to the licensing authority.
Who Needs Surplus Lines Licensee Affidavit?
01
Insurance professionals who operate as surplus lines insurance brokers or agents need a surplus lines licensee affidavit.
02
Individuals who represent agencies or brokerages dealing with surplus lines insurance must also complete this affidavit.
03
It is typically a requirement for obtaining or renewing a surplus lines license and maintaining compliance with state and federal regulations in the insurance industry.
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What is surplus lines licensee affidavit?
Surplus lines licensee affidavit is a document that must be filed by surplus lines insurance licensees to report their transactions which are not placed with licensed insurers.
Who is required to file surplus lines licensee affidavit?
Surplus lines insurance licensees are required to file the surplus lines licensee affidavit.
How to fill out surplus lines licensee affidavit?
Surplus lines licensee affidavit can be filled out electronically or manually, providing information on surplus lines transactions.
What is the purpose of surplus lines licensee affidavit?
The purpose of surplus lines licensee affidavit is to ensure compliance with regulations and proper reporting of surplus lines transactions.
What information must be reported on surplus lines licensee affidavit?
Surplus lines licensee affidavit must include information on the surplus lines transactions, such as the insured, policy details, premiums, and commissions.
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