Get the free Surplus Lines Licensee Affidavit for Purchasing Groups

This form is to be used by surplus lines licensees procuring coverage for purchasing groups. It assists in filing and paying the Oregon surplus lines premium tax and requires detailed information

How to fill out surplus lines licensee affidavit

How to fill out surplus lines licensee affidavit

1. Obtain the surplus lines licensee affidavit form from the state's Department of Insurance website or office.
2. Ensure you have your license information and other relevant details ready.
3. Fill in your name and contact information in the designated sections.
4. Provide details about the surplus lines insurance policies you are reporting, including policy numbers and insured amounts.
5. Confirm that you are meeting all regulatory requirements for surplus lines transactions.
6. Sign and date the affidavit to certify the accuracy of the information provided.
7. Submit the completed affidavit to the appropriate regulatory body by the deadline.

Who needs surplus lines licensee affidavit?

1. Insurance agents and brokers who are licensed to sell surplus lines insurance.
2. Individuals or businesses seeking to place coverage that cannot be found in the traditional insurance market.
3. Companies looking to comply with state regulations regarding surplus lines transactions.

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What is surplus lines licensee affidavit?

A surplus lines licensee affidavit is a legal document affirming the placement of insurance coverage with a non-admitted insurance carrier, indicating that the coverage was not available from licensed insurers.

Who is required to file surplus lines licensee affidavit?

Insurance brokers or agents who place insurance with non-admitted insurers are required to file a surplus lines licensee affidavit.

How to fill out surplus lines licensee affidavit?

To fill out a surplus lines licensee affidavit, complete the form by providing relevant details such as the policyholder's information, details of the insurance coverage, the non-admitted insurer's name, and the reasons for placing the coverage with a surplus lines insurer.

What is the purpose of surplus lines licensee affidavit?

The purpose of the surplus lines licensee affidavit is to ensure compliance with state regulations regarding the placement of insurance, to provide transparency, and to assure that coverage was sought from admitted carriers before relying on surplus lines.

What information must be reported on surplus lines licensee affidavit?

The surplus lines licensee affidavit must report information such as the name of the insured, the type and amount of insurance coverage, the name of the non-admitted insurer, details on efforts to obtain coverage from licensed carriers, and any applicable premiums.