When must the notice be given to the insured?

Provide the notice at or immediately after placement with a nonadmitted insurer. State rules differ on timing for delivery and filing, so confirm local requirements before finalizing placement documentation.

Can the notice be signed electronically?

Yes. Electronic signatures are binding under ESIGN and UETA when intent, consent, attribution, and retention are satisfied. Maintain a complete audit trail to demonstrate who signed and when.

What supporting documents should accompany the notice?

Attach declination evidence or market-search records, the surplus lines affidavit when required, and any premium tax calculations to support stamping office filings and audits.

Who files the notice with the stamping office?

Typically the surplus lines broker or their designated filing agent files with the state stamping office and remits premium taxes; confirm the filing party in your jurisdiction.

How long must placement files be retained?

Retention follows federal and state rules: keep records for at least the federal minimums and longer if state law or industry rules require extended retention, particularly for tax or HIPAA-related records.

What are quick checks before submitting a filing?

Verify broker license and insured legal name, confirm taxable premium basis, attach declination evidence, ensure a signed notice, and check the stamping office’s submission format and deadline.

Electronic Signature
Templates
Insurance
Excess Line Placement Notice

Excess Line Placement Notice

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Excess Line Placement Notice

I. Insured / Applicant Information

Insured Name: Mailing Address:

Date of Birth (if individual): Tax or Identification Number (if applicable):

Entity Type (select one or more as applicable):

Individual Corporation LLC Partnership Trust Other

If Other, describe:

II. Producer / Surplus Lines Broker

Broker / Producer Name: Broker Firm / Agency:

Broker License / License No.: Contact Phone:

Broker Address:

III. Non‑Admitted Insurer / Placement

Non‑Admitted Insurer Name:

State of Domicile: Insurer Identification Number (if any):

IV. Policy Details

Policy Number: Policy Type / Class of Business:

Coverage Limit: $ Deductible / Retention: $ Annual Premium: $

Policy Period: From to Placement Date:

V. Coverages Placed (Check all that apply)

General Liability (Occurrence/Claims-Made) Excess / Umbrella Liability Professional / Errors & Omissions Liability Property (All Risk / Named Perils) Cyber Liability Commercial Auto Workers' Compensation (if non-admitted placement permitted) Other

If Other, describe coverage and limits:

VI. Exclusions and Important Disclosures

This coverage has been placed with a non‑admitted (surplus lines) insurer that is not licensed in the jurisdiction where the insured is located. Coverage provided by a non‑admitted insurer may not be subject to the same regulatory oversight, guaranty funds, or insolvency protections as admitted carriers. The insured acknowledges receipt of this notice and understands the differences in regulatory protections.

Standard exclusions that commonly apply to non‑admitted placements include, but are not limited to, losses arising from: intentional acts or willful misconduct; known prior acts or circumstances disclosed to prior insurers; war or hostile acts; nuclear hazard; pollution unless specifically endorsed; and liabilities assumed under contract beyond common law obligations. The specific policy forms and endorsements attached to the policy control the scope of coverage and exclusions.

Acknowledgment of Exclusions and Notice:

I acknowledge that I have read and understand the exclusions and the nature of placement with a non‑admitted insurer.

VII. Taxes, Fees and Payment

Surplus lines premium taxes and any applicable stamping fees may be due in the jurisdiction where the risk is located. Unless otherwise agreed in writing, payment of premium, taxes and fees is the responsibility of the insured as set forth in the policy or brokerage agreement.

Surplus Lines Tax Responsibility: Broker Insured Other

If Other, specify:

VIII. Beneficiary / Payee Information (If Applicable)

Beneficiary / Payee Name:

Relationship to Insured: Percentage of Proceeds: %

IX. Attachments and Documentation

The following documents are attached or will be provided in connection with this placement (check all applicable):

Policy forms and endorsements Coverage summary / dec page Insured application / submission materials Broker placement certification / affidavit

If other documentation attached, describe:

X. Declaration and Applicant Certification

By signing below, the Applicant/Insured certifies and acknowledges that: (a) the insurance described above has been placed with a non‑admitted insurer through the identified broker; (b) the broker provided the Applicant with a disclosure regarding non‑admitted placement and performed the usual placement diligence required by applicable law and regulation; (c) the Applicant has received or will receive policy forms, endorsements, and the declaration page; and (d) the Applicant understands the potential differences in regulatory protections and agrees to comply with any premium, tax or fee obligations arising from this placement.

The Applicant further certifies that the information contained in this notice is true, complete and accurate to the best of the Applicant's knowledge and that no material facts have been intentionally omitted.

Applicant / Insured:

By:

Date:

What the Excess Line Placement Notice Is

An Excess Line Placement Notice documents placement of insurance with nonadmitted (surplus lines) carriers when required coverage is unavailable from admitted insurers. The notice records broker and insured information, identifies the policy and coverages placed on a nonadmitted basis, and explains tax and reporting obligations that typically follow placement. It supports regulatory transparency, evidences broker due diligence in the surplus lines market, and serves as the administrative record used for stamping office filing, premium tax calculation, and the insured’s file.

Why a Clear, Accurate Notice Matters

A properly completed Excess Line Placement Notice preserves compliance with surplus lines rules, supports accurate premium tax reporting, and documents the broker’s attempt to place coverage in the admitted market before using nonadmitted carriers.

Who Typically Prepares and Receives This Notice

Keep a signed copy in both the broker file and the insured’s policy records to support audits and tax reporting.

Licensed surplus lines broker preparing required placement documentation and filing reports with the stamping office or state regulator.
Risk managers or insureds reviewing placement for tax, policy limits, and regulatory disclosure.
Compliance teams maintaining records to demonstrate diligent efforts to place with admitted carriers first.

Roles Who Sign and Approve the Notice

Surplus Lines Broker

A licensed surplus lines broker or placing agent signs or certifies the notice after documenting the search of admitted markets and confirming placement with a nonadmitted insurer. The broker’s entry typically includes license number, company name, and signature authority to validate regulatory compliance.

Named Insured

An authorized representative of the insured signs or acknowledges receipt when required by state rules; that signature confirms the insured was informed the coverage is placed with a nonadmitted insurer and may be subject to different regulatory protections.

Essential Elements of a Professional Placement Notice

A complete Excess Line Placement Notice combines identifying details, placement rationale, and administrative markers used for filing and taxation; format and required fields vary by state but core elements remain consistent.

Broker Identification

Full broker or agency name, license number, contact information, and broker signature or electronic certification to show who facilitated placement and who is responsible for filing.

Insured Details

Named insured, mailing address, policyholder contact, and any additional named insureds; accuracy here ties the notice to the correct policy record and tax account.

Risk Description

Plain-language description of the risk or property insured, policy period, location, and underwriting class so regulators and auditors can verify coverage purpose.

Policy and Insurer Data

Nonadmitted insurer name, policy number, coverage limits, premium amounts, effective dates, and any endorsements or special terms relevant to surplus lines reporting.

Placement Justification

Documentation of diligent efforts to place with admitted carriers, including dates and results of declinations or market searches, supporting the necessity of surplus lines placement.

Filing and Tax Flags

Indication of stamping office filing, premium tax amounts or taxable premium basis, and internal reference numbers used for state reporting and remittance.

Required Data Fields at a Glance

Broker Name: Full legal name

Broker License: Number and state

Insured Name: Legal entity

Policy Number: Carrier policy ID

Premium: Total premium

Effective Dates: MM/DD/YYYY range

Step-by-Step: Completing the Notice

Follow these steps in sequence to prepare a compliant Excess Line Placement Notice and streamline subsequent filings.

01

Gather Records: Collect declination or market search evidence before filling the notice.
02

Enter Identifiers: Fill broker, insured, and policy fields exactly as issued.
03

Calculate Premiums: Confirm taxable premium basis per state rules before entering amounts.
04

Sign and Save: Obtain required signatures and save a timestamped copy for filings.

Where the Notice Goes and Who Sees It

Understand the routing chain so every recipient gets the required information for compliance and tax reporting.

Insured Copy: Deliver to the insured at or shortly after placement.
Broker File: Retain in the broker’s placement file for audit support.
Stamping Office: File with the state stamping office if required by jurisdiction.
Tax Remittance: Use notice data to calculate and remit surplus lines taxes.

eSubmission and Platform Considerations

Choose a platform that supports secure storage, audit logs, and the export formats required by your state stamping office or regulator.

File Formats: PDF and DOCX accepted; preserve original layout for stamping office review.
Integrations: CRM and storage integrations (Salesforce, NetSuite, Microsoft 365) reduce manual entry and duplication.
Authentication: Use signer authentication and detailed audit trails to strengthen evidentiary value.

Typical Online Workflow for Completing and Filing

Configure a repeatable workflow that collects necessary fields, enforces required signatures, and routes documents to filing or tax teams.

Field	Configuration
Upload Document	Add completed notice PDF \| Verify fields auto-detected
Broker Info	Populate license number \| Auto-fill from broker profile
Insured Details	Populate legal name \| Validate with CRM
Affidavit Attachment	Attach surplus lines affidavit \| Include declination evidence
Routing	Send to insured, broker file, and tax/stamping team

Common Mistakes to Avoid

Entering mismatched insured names or broker license numbers, which can delay stamping office validation and tax remittance.
Failing to attach declination evidence or market search records, undermining the required justification for nonadmitted placement.
Using inconsistent premium bases (gross vs taxable premium) when calculating surplus lines tax, causing incorrect tax filings.
Not retaining signed copies or audit logs long enough to support state examinations or audits of surplus lines placements.

Consequences of Incorrect or Missing Notices

Tax Assessment: Additional premium tax due

Fines: Civil penalties may apply

Regulatory Audit: Increased regulator scrutiny

Coverage Disputes: Claims complications

Broker Sanctions: License discipline possible

Reputational Risk: Client trust erosion

Practical Tips for Accurate Notices

Apply consistent internal controls and use checklists to minimize errors and accelerate filing.

Standardize Templates

Use a single validated notice template across the agency to ensure required fields are present, formats are consistent, and declination evidence is attached before routing for signature and filing.

Automate Key Fields

Integrate broker license details and insured records from CRM to avoid manual typing errors and speed population of policy numbers, premium figures, and contact details for stamping office submissions.

Maintain Audit Trail

Capture signer authentication, timestamps, IP addresses, and document history to support audits and provide evidence of intent and receipt under ESIGN and UETA frameworks.

Confirm Filing Rules

Before placement, verify state stamping office deadlines and tax rules; update internal workflows to reflect jurisdictional differences and remittance timelines to avoid late fees.

Real-World Examples of Digital Notice Management

These examples illustrate how digitized notices and workflows reduce friction in surplus lines placement and recordkeeping.

Martin Properties

A mid-size property manager moved notices online to speed tenant and insurer acknowledgements.

Adoption reduced manual processing steps.
The firm retained timestamped records for audits and improved file retrieval across multiple properties, cutting administrative delays.

BIS

An enterprise broker standardized notices across offices for consistent tax reporting.

Centralized templates and audit trails improved compliance.
The broker reported fewer filing corrections and clearer records for stamping office submissions during state reviews.

Timing Expectations and Typical Deadlines

Timely delivery and filing vary by state; follow placement, issuance, and filing sequence to avoid late remittances or penalties.

At Placement:

Deliver notice to insured immediately upon placing with a nonadmitted insurer

Policy Issuance:

Provide the insured with the finalized policy and declarations when issued

Stamper Filing:

File with stamping office per state rules; timing varies by jurisdiction

Tax Remittance:

Remit surplus lines taxes by the state’s filing deadline

Record Retention:

Maintain documentation according to federal and state retention requirements

eSignature Vendor Comparison for Notice Workflows

Compare common vendor attributes for completing and distributing Excess Line Placement Notices; signNow is listed first for consistency in evaluation.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Yes	Yes	Yes	Yes
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies by plan	Varies by plan	Varies by plan

Frequently Asked Questions

Answers to common questions about completing, delivering, and filing an Excess Line Placement Notice.

Need help? Contact support

When must the notice be given to the insured?
Provide the notice at or immediately after placement with a nonadmitted insurer. State rules differ on timing for delivery and filing, so confirm local requirements before finalizing placement documentation.
Can the notice be signed electronically?
Yes. Electronic signatures are binding under ESIGN and UETA when intent, consent, attribution, and retention are satisfied. Maintain a complete audit trail to demonstrate who signed and when.
What supporting documents should accompany the notice?
Attach declination evidence or market-search records, the surplus lines affidavit when required, and any premium tax calculations to support stamping office filings and audits.
Who files the notice with the stamping office?
Typically the surplus lines broker or their designated filing agent files with the state stamping office and remits premium taxes; confirm the filing party in your jurisdiction.
How long must placement files be retained?
Retention follows federal and state rules: keep records for at least the federal minimums and longer if state law or industry rules require extended retention, particularly for tax or HIPAA-related records.
What are quick checks before submitting a filing?
Verify broker license and insured legal name, confirm taxable premium basis, attach declination evidence, ensure a signed notice, and check the stamping office’s submission format and deadline.

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