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Insurance Surplus Disclosure

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INSURANCE SURPLUS DISCLOSURE

Applicant / Insured Information

Producer / Broker Information

Insurer & Policy Details

Insurer Name:   State of Domicile:

Policy Number:    Policy Type:

Coverage Selections

Indicate coverages provided under this policy (check all that apply):

Property    Casualty / General Liability    Excess / Umbrella    Professional Liability

Inland Marine    Automobile    Marine    Other:

Exclusions and Limitations

State any material policy exclusions or limitations that are specific to this placement. This disclosure supplements the policy; the policy language controls coverage obligations.

Surplus Lines Disclosure and Acknowledgements

Important: The insurer identified above is not licensed (non-admitted) in the Insured's state. Policies placed with non-admitted insurers are not covered by the state's insurance guaranty association and may not be subject to state rate or form filing requirements. The Insured should read the policy carefully and retains responsibility for payment of any applicable surplus lines taxes and regulatory fees assessed by the state.

I acknowledge that the insurer is non-admitted in my state and that coverage under this policy is not covered by the state guaranty association.

I acknowledge that premium taxes, stamping fees, or other regulatory charges may apply and are the responsibility of the Insured unless otherwise stated in the policy or invoice.

I acknowledge that the terms, conditions and exclusions contained in the policy govern coverage and that this disclosure does not modify those terms.

Market Placement Statement (Broker Attestation)

The broker attests that a search of admitted markets was conducted and that coverage was not available at reasonable terms or was otherwise unavailable prior to placement with a surplus lines insurer. Provide a succinct description of placement efforts, including admitted carriers contacted, dates, and reasons for declination or unavailability.

Broker attests that the foregoing market search was conducted in good faith and that placement in the surplus lines market was necessary.

Beneficiary Designation (If Applicable)

If the policy provides proceeds payable to a beneficiary, complete the following. If not applicable, check the Not applicable box.

Not applicable

Declaration and Certification

By signing below, the Insured certifies under penalty of perjury that the information provided in this disclosure is true and correct to the best of the Insured's knowledge and that the Insured has read and understands the Surplus Lines Disclosure above. The Insured acknowledges receipt of a copy of this disclosure.

Applicant / Insured:

Signature:

Date:

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What an Insurance Surplus Disclosure Is and when it's used

An Insurance Surplus Disclosure is a written statement provided when coverage is placed with a nonadmitted or surplus lines insurer to explain that the insurer is not licensed in the insured's state, to itemize premium, taxes, and fees, and to describe differences from admitted-market policies. It documents broker and carrier identity, policy terms relevant to gaps or limits, and any broker fees or premium finance arrangements. The disclosure is primarily a consumer-protection record used by brokers, insureds, regulators, and stamping offices to confirm proper placement and payment of applicable surplus lines taxes.

Why the Insurance Surplus Disclosure matters for compliance and clarity

A clear surplus disclosure reduces regulatory risk, documents tax and fee allocation, and preserves the insured's informed consent when coverage is placed outside admitted markets; it supports audits and helps establish the broker's compliance with state stamping office rules.

Why the Insurance Surplus Disclosure matters for compliance and clarity

Typical users and recipients of the disclosure

The disclosure serves multiple stakeholders: it evidences compliance for regulators, informs insureds, and documents broker and carrier responsibilities.

  • Surplus lines brokers who place nonadmitted coverage and must document placement to the insured and stamping office.
  • Insured parties, including corporate risk managers and individual policyholders who need clear statement of coverage status and fees.
  • State stamping offices and regulators that require proof of placement, taxes, and premium reporting for surplus lines.

Who typically signs or completes the form

Surplus Lines Broker

A licensed surplus lines broker or appointed producer completes placement details, certifies tax calculation, and signs the disclosure. Brokers maintain copies for stamping office filings and audits and should include broker contact, license number, and declaration of authority.

Corporate Risk Manager

A company risk manager or authorized representative reviews and signs to acknowledge receipt and understanding. Signature confirms the insured received notice that the insurer is nonadmitted and accepts the coverage terms and any broker fees disclosed.

Core elements every professional disclosure should include

A complete Insurance Surplus Disclosure collects identification, financial, and legal elements so each party and regulator can confirm placement and tax handling.

Insurer Details

Name of nonadmitted insurer, NAIC or other identifier if available, state of domicile, and any policy form or endorsement numbers necessary to identify the contract of insurance.

Coverage Summary

High-level description of insured locations, covered perils, limits, deductibles, and special exclusions that differ from admitted-market policies and may affect coverage expectations.

Premium and Fees

Itemize gross premium, broker fees, surplus lines taxes, stamping office fees, and any premium finance charges so total cost and tax allocation are transparent.

Broker Statement

Certification that the broker placed coverage with a nonadmitted insurer because admissible coverage was unavailable or inadequate, and a statement of placement rationale if required by state law.

Authorized Signature

Signature block for broker and insured with printed name, title, date, and contact information to confirm receipt and acceptance of the disclosure.

Attachments

Include the actual policy declarations page, premium invoice, stamping office filing receipt, and any premium finance agreement as exhibits to the disclosure.

Security and compliance facts to record with the disclosure

Encryption: TLS 1.2/1.3; AES-256 at rest
Access Control: Role-based permissions; audit logging
Audit Trail: Timestamped actions and signer metadata
HIPAA BAA: Available when PHI is present
Retention Flags: Immutable copies and version history
Authentication: Email, SMS code, or stronger options

Step-by-step: completing an Insurance Surplus Disclosure

Follow these core steps to prepare a compliant disclosure from data entry through signature and filing.

  • 01
    Gather documents: Collect policy, invoice, and broker license details.
  • 02
    Populate fields: Enter insurer, insured, premium, taxes, and fee line items.
  • 03
    Review with insured: Confirm placement rationale and cost allocation.
  • 04
    Sign and file: Obtain signatures and submit to stamping office if required.

How to set up the disclosure workflow online

Configure field validation, signer order, and delivery so disclosures are accurate and auditable.

Field Validation | Required format
Insured Name Exact legal name | No abbreviations
Effective Date MM/DD/YYYY | Auto-validate
Premium Line Items Numeric currency | Two decimals
Signer Order Broker then insured | Sequential routing

Where to send, file, and retain the signed disclosure

A standard routing ensures the insured receives notice, regulators get required copies, and records are retained for audit.

  • Deliver to Insured: Email or attach signed disclosure to policy packet for insured records.
  • Submit to Stamping Office: File required surplus lines forms and fees per state stamping office rules.
  • Provide Carrier Copy: Retain insurer endorsement and declarations page with disclosure.
  • Archive for Audit: Store digital copy in secure records with retention tags.

Distribution channels and technical requirements

Use platforms that support PDF, DOCX, and audit trails and integrate with common systems like Salesforce, NetSuite, or cloud storage to simplify distribution and recordkeeping.

  • Email Delivery: Secure PDF with audit certificate
  • Portal Access: Authenticated insured downloads
  • API Filing: Integration to stamping office systems

Typical timelines and processing expectations

Timing for delivery and filing varies by state; follow broker of record, insured acknowledgement, and stamping office timelines to avoid late penalties.

Deliver to Insured:

Provide disclosure at placement or per state timing requirements.

Stamper Filing:

File with stamping office as required by jurisdiction; timeframes vary.

Premium Payment:

Collect and remit taxes per state schedule and invoice terms.

Record Retention:

Keep executed disclosure accessible for audits and compliance.

Correction Window:

Correct material errors promptly and refile if required by regulator.

Common preparation errors to avoid

  • Incomplete insurer identification, which complicates stamping office matching and auditor review.
  • Omitting broker fee details or premium financing charges, leaving tax basis and insured costs unclear.
  • Using inconsistent insured names across policy, invoice, and disclosure, causing potential tax or claims disputes.
  • Failing to capture signature metadata or audit trail that demonstrates insured consent to nonadmitted placement.

Regulatory and contractual risks of incorrect disclosures

Regulatory Fines: Civil penalties and assessments
Tax Exposure: Unpaid surplus lines taxes due
Coverage Disputes: Claims denial risks for improper notice
Audit Findings: Broker sanctions or corrective filings
Client Relations: Loss of trust or brokerage liability
Record Deficiencies: Inadequate retention or missing audit trail

Supporting documents and export options to include

Include standard exhibits and make copies available in common formats so filings and audits proceed smoothly.

Supporting Documents

Attach the declarations page, premium invoice, stamping office receipt, and any premium finance agreement so the disclosure is fully substantiated for review.

Export Formats

Provide final executed disclosures as PDF/A for archival, plus downloadable DOCX for editing and XML/CSV for bulk reporting where required.

Version Control

Track revisions and preserve an immutable final executed copy; include a certificate of completion to show audit metadata.

Audit Certificate

Include signer IP, timestamps, and authentication method in an attached audit record to support compliance and non-repudiation.

How organizations use the Insurance Surplus Disclosure in practice

Real-world examples show how disclosures support placement, auditability, and client communication.

Martin Properties

Local brokerage adapted a surplus disclosure template for property placements to speed closings and improve clarity.

  • Quick verification of premiums and taxes reduced follow-ups.
  • The broker reported fewer client questions and faster stamping office reconciliation after standardizing disclosures and storing executed copies centrally for three years.

Fertility Centers of Illinois

A healthcare provider used a standardized disclosure with HIPAA-aware redaction rules when sharing policy documents.

  • Protected PHI while meeting insurer information needs.
  • This approach preserved patient confidentiality, satisfied internal compliance, and ensured the broker could file required paperwork without exposing unnecessary medical data.

Frequently asked questions about the Insurance Surplus Disclosure

Answers to common questions on timing, signing, filing, and correcting disclosures.


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eSignature platform pricing and feature comparison for managing disclosures

Compare common eSignature plans and capabilities relevant to executing and storing Insurance Surplus Disclosures; signNow is listed first for parity with other providers.

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 Yes, 7-day trial No No Yes, limited Yes, limited
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
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