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***A.R.S. 20-413(F) CERTIFICATE OF SURPLUS LINES BROKER *** TO BE RETURNED BY THE SURPLUS LINES BROKER TO THE: PROPERTY/CASUALTY DIVISION STATE OF ARIZONA -- DEPARTMENT OF INSURANCE 2910 NORTH 44TH

How to fill out certificate of surplus lines

How to fill out a certificate of surplus lines:

1. Obtain the necessary form: Start by obtaining the specific form for the certificate of surplus lines. This form can usually be found on the website of the relevant insurance regulatory authority or obtained from an insurance broker or agent.
2. Fill in the insured's information: Begin by providing the necessary information about the insured party. This typically includes their name, address, contact details, and any other requested information.
3. Provide policy details: Fill in the details of the insurance policy for which the surplus lines coverage is being sought. This includes the policy number, effective dates, and any other pertinent information related to the insurance policy.
4. Specify the coverage: Clearly state the types of coverage being provided by the surplus lines insurance. This can include property, liability, marine, or any other specific coverage types.
5. Indicate the surplus lines broker: Enter the name, address, and license number of the surplus lines broker facilitating the coverage. This information ensures that the broker is authorized to act on behalf of the insured party in obtaining the surplus lines insurance.
6. Provide the insurer's information: Include the name, address, and any other relevant details of the surplus lines insurer providing the coverage. This information must accurately identify the insurer and ensure its compliance with the regulatory requirements for surplus lines insurance.
7. Sign and date the certificate: Once all the necessary information has been provided, sign and date the certificate. This signifies that the information provided is true and accurate to the best of the signer's knowledge.

Who needs a certificate of surplus lines:

1. Businesses with unique or high-risk insurance needs: A certificate of surplus lines is often required for businesses that have unique or high-risk insurance needs that cannot be met by traditional insurance carriers. Surplus lines insurance provides coverage for risks that are not typically insurable through standard insurance markets.
2. Insurance brokers and agents: Insurance brokers and agents play a crucial role in facilitating the placement of surplus lines insurance. They connect businesses with surplus lines insurers and help them navigate the complex landscape of non-admitted insurance.
3. Regulatory authorities: Regulatory authorities responsible for overseeing the insurance industry require a certificate of surplus lines to ensure compliance with applicable laws and regulations. This certificate provides transparency and accountability in the surplus lines market.

For pdfFiller’s FAQs

What is certificate of surplus lines?

A certificate of surplus lines is a document that is filed by insurance brokers or agents to report coverage placed with non-admitted insurance companies.

Who is required to file certificate of surplus lines?

Insurance brokers or agents who place coverage with non-admitted insurance companies are required to file a certificate of surplus lines.

How to fill out certificate of surplus lines?

The certificate of surplus lines can be filled out electronically or on paper, and typically requires information about the insured, the coverage placed, the non-admitted insurance company, and the premium amount.

What is the purpose of certificate of surplus lines?

The purpose of the certificate of surplus lines is to ensure that coverage placed with non-admitted insurance companies is properly reported and regulated.

What information must be reported on certificate of surplus lines?

Information such as the name of the insured, the policy number, the effective date of coverage, the premium amount, the non-admitted insurance company, and the signature of the broker/agent must be reported on the certificate of surplus lines.

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