FL Surplus Lines Disclosure and Acknowledgement 2022-2026 free printable template

Surplus Lines Disclosure and Acknowledgement At my direction, name of insurance agency has placed my coverage in the surplus lines market. As required by Florida Statute 626.916, I have agreed to

How to fill out FL Surplus Lines Disclosure and Acknowledgement

How to fill out FL Surplus Lines Disclosure and Acknowledgement

1. Begin by downloading the FL Surplus Lines Disclosure and Acknowledgement form from the state website or your insurance provider.
2. Fill in the name of the insured at the top of the form.
3. Provide the address of the insured in the designated section.
4. Enter the policy number associated with the surplus lines insurance.
5. List the specific coverages being obtained under the surplus lines policy.
6. Include detailed information about the surplus lines insurer, including their name and state of domicile.
7. Verify that the insurer has been approved by the Florida Office of Insurance Regulation.
8. Sign and date the acknowledgment section, confirming your understanding of the surplus lines nature of the policy.
9. Submit the completed form to the appropriate parties, such as the insurance agent or your insurance company.

Who needs FL Surplus Lines Disclosure and Acknowledgement?

1. Individuals or businesses seeking coverage through a surplus lines insurer.
2. Insurance agents who are facilitating the purchase of surplus lines coverage.
3. Companies that are non-admitted in Florida but provide necessary insurance products for specific risks.

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What is FL Surplus Lines Disclosure and Acknowledgement?

FL Surplus Lines Disclosure and Acknowledgement is a document that informs clients about the purchase of surplus lines insurance in Florida, emphasizing that this type of insurance may not be regulated in the same way as standard insurance.

Who is required to file FL Surplus Lines Disclosure and Acknowledgement?

Licensed surplus lines agents in Florida are required to file the FL Surplus Lines Disclosure and Acknowledgement when placing insurance coverage with non-admitted insurers.

How to fill out FL Surplus Lines Disclosure and Acknowledgement?

To fill out the FL Surplus Lines Disclosure and Acknowledgement, the agent must provide details such as the insured's name, the type of coverage, and the non-admitted insurer’s information, along with a signature from the insured acknowledging the disclosure.

What is the purpose of FL Surplus Lines Disclosure and Acknowledgement?

The purpose of FL Surplus Lines Disclosure and Acknowledgement is to ensure that consumers are aware they are purchasing surplus lines insurance, which may carry different risks and protections compared to standard insurance.

What information must be reported on FL Surplus Lines Disclosure and Acknowledgement?

The information that must be reported includes the insured's details, the type of insurance being purchased, the non-admitted insurer's name and contact information, and a statement acknowledging the client’s awareness of the nature of surplus lines insurance.