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SURPLUS LINES DISCLOSURE and ACKNOWLEDGEMENT At my direction, Ensure Inc has placed my coverage in the surplus lines market. As required by Florida Statute 626.916, I have agreed to this placement.

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How to fill out Florida surplus lines disclosure:

1. Obtain the necessary forms: Begin by obtaining the Florida surplus lines disclosure form. This form can typically be obtained from the surplus lines association or insurance department in Florida.
2. Fill out the applicant information: Provide the required information about the applicant, such as their name, address, contact details, and any other relevant personal information.
3. Provide details about the insured: Enter the necessary details about the insured party, including their name, address, and any other relevant information.
4. Describe the nature of the coverage: Clearly and accurately describe the type of coverage being provided, including any limitations or exclusions.
5. Disclose the surplus lines broker and insurance carrier: Provide the name and contact details of the surplus lines broker who is facilitating the coverage, as well as the name of the insurance carrier.
6. Include the premium and coverage details: Specify the premium amount and the duration of coverage being provided.
7. Sign and date the disclosure: Once all the necessary information has been entered, sign and date the surplus lines disclosure form.
8. Retain a copy of the completed form: Keep a copy of the filled-out surplus lines disclosure form for your records.

Who needs Florida surplus lines disclosure?

1. Insurance Brokers: Insurance brokers operating in Florida are required to provide a surplus lines disclosure to clients when placing coverage with a non-admitted insurance carrier.
2. Insured Parties: Anyone who is obtaining insurance coverage from a surplus lines insurance carrier in Florida may need to complete and sign a surplus lines disclosure form.
3. Surplus Lines Association: The Florida Surplus Lines Association may require certain parties to fill out the surplus lines disclosure form as part of their regulatory and compliance requirements.

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What is Florida surplus lines disclosure?

Florida surplus lines disclosure is a document that informs policyholders when they are purchasing surplus lines insurance, which is coverage not available through licensed insurers in the state.

Who is required to file Florida surplus lines disclosure?

Insurance agents or brokers who sell surplus lines insurance are required to file the Florida surplus lines disclosure.

How to fill out Florida surplus lines disclosure?

To fill out the Florida surplus lines disclosure, the agent should provide details of the insurance policy, including the insured's name, the type of coverage, the insurer's name, and any relevant terms or conditions.

What is the purpose of Florida surplus lines disclosure?

The purpose of the Florida surplus lines disclosure is to ensure that consumers understand they are purchasing insurance from a non-admitted insurer and to outline the potential risks involved.

What information must be reported on Florida surplus lines disclosure?

The information that must be reported includes the name and address of the insured, details of the coverage being purchased, name of the surplus lines insurer, terms of the policy, and any specific exclusions or limitations.