Insurance Admitted Market Declinations

Insurance Admitted Market Declinations

Complete this form to document bona fide attempts to obtain coverage from admitted insurers licensed in the applicable jurisdiction(s). This form provides contemporaneous record of contacts, declination reasons, and supporting documentation. All entries must be true and accurate to the best of the undersigned's knowledge.

1. Applicant / Insured Information

2. Producer / Broker Information

3. Policy Details and Coverage Requested

Coverage Type (check all that apply):

4. Admitted Market Contact Log

Record each admitted carrier contacted. Include date, method, declination reason(s), and whether written declination was obtained. Attach copies of written declinations and correspondence.

5. Common Declination Reasons (Summary)

Indicate primary reasons encountered in the admitted market.

6. Exclusions and Limitations

The declinations recorded on this form are statements of marketplace response and do not constitute an admission of coverage availability or create any binding insurance contract. Insurers may decline for reasons including, but not limited to, unacceptable risk profile, prior loss experience, jurisdictional restrictions, underwriting guidelines, capacity constraints, or failure to meet underwriting information requests. This list is illustrative and not exhaustive.

7. Beneficiary Information (If Applicable)

8. Declaration and Certification

I certify, under penalty of perjury and the applicable laws of the jurisdiction(s) in which this form is executed, that:

1. All information provided on this form is true, correct and complete to the best of my knowledge;
2. The broker/producer identified herein made good faith efforts to solicit admitted insurers for the coverage requested and recorded the responses contemporaneously;
3. Any written declinations attached or noted are accurate copies or faithful summaries of the communications received; and
4. I understand that completion of this form does not bind coverage or create any contractual obligation on the part of any insurer, and that any coverage is subject to acceptance and issuance of a policy by an insurer.

Authorization: I authorize any insurer or representative to release underwriting and declination information to the producer and to the reporting entity preparing this form for the purpose of placement or documentation of declinations.

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