Can this form be signed electronically?

Yes in most states if the signature meets ESIGN and UETA requirements: intent to sign, consent to electronic records, reliable attribution, and the ability to retain a reproducible record. Confirm any consumer disclosure obligations under 15 U.S.C. ch. 96 for consumer‑facing transactions.

Is notarization ever required?

Some states or filing processes may request notarized acknowledgements for specific placements. Check the state surplus lines office rules; where notarization is required, ensure the notary method (in‑person or RON) complies with state notary law.

What happens if the insured won’t sign?

Document attempts to obtain signature, provide the disclosure in writing, and note the refusal. Retain evidence of delivery; consult counsel if the insured’s refusal affects coverage or compliance.

How should tax be shown on the form?

Show gross premium, tax rate, and calculated tax amount clearly. If tax is pending, indicate 'To be billed' and reconcile promptly to avoid state penalties for underpayment.

Where do I file the acknowledgement?

Filing locations depend on the state: some require submission to a stamping or surplus lines reporting office, others accept electronic reporting through a designated portal; verify the destination with the state regulator.

How long must I keep the signed acknowledgement?

Retain for the life of the policy plus at least three years; for tax and HIPAA‑related records follow IRC §6501(a) and 45 CFR §164.530(j) respectively, and check for any state extensions.

Electronic Signature
Templates
Insurance
Insurance Surplus Lines Acknowledgement

Insurance Surplus Lines Acknowledgement

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

INSURANCE SURPLUS LINES ACKNOWLEDGEMENT

Insured / Applicant Information

Insured Name DBA / Additional Name (if applicable) Mailing Address

Contact Name

Phone

Email

Date of Birth / Formation Date

Producer / Surplus Lines Insurer

Broker / Producer Name

Broker License Number

Broker Mailing Address

Surplus Lines Insurer Name

Insurer Domicile

Surplus Lines Policy Number

Policy Details

Policy Type

Coverage Limit

Deductible

Annual Premium

Policy Period From:

To:

Reason(s) for Surplus Lines Placement

The undersigned acknowledges that the following reason(s) apply to placement of coverage with a surplus lines insurer. Select all that apply.

Coverage not reasonably available from insurers licensed in the state Required limits/excess capacity not available in admitted market Unique or high-hazard exposure requiring non-admitted capacity Time-sensitive placement or binder necessity Insured specifically requested surplus lines placement Other:

Acknowledgements and Disclosures

By initialing and signing below, the Applicant expressly acknowledges and agrees to the following terms. Initial each applicable acknowledgement where indicated.

I acknowledge that the surplus lines insurer is not licensed in this state and that coverage placed with a non-admitted insurer is not protected by this state's insurer insolvency guaranty fund or similar guaranty mechanisms. I acknowledge that surplus lines carriers are not subject to the same regulatory requirements as admitted carriers in this state and that policy terms, filing requirements, and rates may differ. I understand that claims handling and dispute resolution may be governed by the laws of the insurer's domicile and by the policy language; remedies available under state law for admitted insurers may not apply. I confirm that the producer/broker has made reasonable efforts to place coverage with admitted insurers and has documented those efforts, and that I consent to placement on a surplus lines basis. I acknowledge that premium taxes, stamping fees, or other regulatory fees may apply to surplus lines placements and may be shown as separate charges on the premium billing.

Exclusions and Limitations

The Applicant acknowledges that the policy issued by the surplus lines insurer is subject to the insurer's policy terms, conditions, exclusions, endorsements, and limits. Applicant further acknowledges the following specific limitations:

1. No Assumption of Guaranty Fund Protection: In the event of insurer insolvency, the Applicant may not be entitled to protection under state guaranty funds. The broker has explained this limitation and Applicant understands the consequence.

2. Applicable Law and Venue: Claims under this policy may be governed by the laws of the insurer's domicile and contractual dispute resolution provisions. Applicant accepts that certain statutory protections available to insureds of admitted carriers may not apply.

3. Policy Terms Prevail: This acknowledgement does not create, modify, or expand coverage. Coverage is governed exclusively by the language of the issued policy and endorsements.

Additional Remarks or Agreed Modifications (if any)

Declaration and Applicant Certification

I, the undersigned Applicant or authorized representative, declare under penalty of perjury that the information provided in this acknowledgement is true and correct to the best of my knowledge. I certify that I have read and understand the disclosures above and that the producer has explained the consequences of placing coverage with a surplus lines insurer. I authorize the producer to effect this placement on my behalf.

Client Name:

Title / Capacity:

Date of Acknowledgement:

Applicant Name:

Signature:

Date:

What an Insurance Surplus Lines Acknowledgement Is

An Insurance Surplus Lines Acknowledgement is a written disclosure provided to an insured when coverage is placed with a non-admitted (surplus lines) insurer. The form documents the broker placing the coverage, identifies the non-admitted insurer, summarizes coverage and premium charges, and explains that the insurer is not licensed in the insured’s state. It supports regulatory reporting, premium tax remittance, and the insured’s informed consent where required by state surplus lines laws. The acknowledgement typically accompanies the policy, certificate, or binder and becomes part of the insurance record.

Why the Acknowledgement Matters for Compliance and Transparency

The Insurance Surplus Lines Acknowledgement documents regulatory disclosure, protects brokers and insureds, and supports state stamping and tax reporting. It clarifies the admission status of the insurer, records premium and tax treatment, and evidences the insured’s receipt of required consumer information to reduce regulatory exposure and placement disputes.

Typical Users and their Responsibilities

Brokers, surplus lines carriers, and insureds commonly exchange the acknowledgement as part of placement paperwork; compliance staff and auditors also rely on it.

Surplus lines brokers — Prepare acknowledgement, ensure accurate insurer and premium details, and file required reports.
Insureds / policyholders — Review disclosure, confirm understanding that insurer is non-admitted, and sign where required.
Compliance and finance teams — Track premium taxes, maintain stamping records, and retain the acknowledgement for audits.

Each party’s role should be defined in brokerage workflows to ensure correct completion, timely filing, and record retention.

Core Elements to Include in a Professional Acknowledgement

A complete acknowledgement groups identity, policy, financial, and legal disclosure information so regulators and insureds can verify placement details quickly.

Insurer Details

Legal name, NAIC number (if available), domicile, and admission status; this lets regulators confirm the insurer is non‑admitted in the insured’s state and supports stamping requirements.

Broker Information

Broker name, license number, surplus lines license state, and contact details; used for filing, premium tax remittance, and follow‑up inquiries by the insured or regulator.

Policy Description

Policy number or binder, coverage period, limits, and key endorsements; concise policy descriptors reduce ambiguity during audits or claims review.

Premium and Taxes

Gross premium, fees, applicable surplus lines premium taxes, and how tax was calculated; explicit tax disclosure aids accurate state reporting and remittance.

Disclosure Statement

Clear consumer-facing language stating the insurer is not licensed in the insured’s state and noting any implications for guaranty funds or state protections.

Signature Block

Space for the insured’s signature and date, broker attestation, and, when required, a notary or witness acknowledgment for state filing or acceptance.

Essential Data Points to Record

Insurer: Full legal name

Broker: Name and license

Policy: Number and period

Premium: Gross premium amount

Taxes: Surplus lines tax amount

Signatures: Insured and broker

Primary Penalties and Compliance Risks

Filing Failure: Late or missing filings can trigger fines

Tax Underpayment: State penalties and interest may apply

Invalid Disclosure: Failure to notify insured risks enforcement

Name Mismatch: Audits and acceptance delays

Signatory Error: Unsigned or improper signatures void acknowledgement

Record Retention: Insufficient retention impedes audits

Step-by-Step: Completing and Delivering the Acknowledgement

Follow these steps in sequence to prepare a compliant acknowledgement and ensure timely filing with regulators and delivery to the insured.

01

Gather Documents: Collect policy, insurer acceptance, and premium calculations.
02

Complete Form: Enter insurer, broker, policy, premium, and tax fields precisely.
03

Obtain Signatures: Secure insured and broker signatures; notarize if required.
04

File and Distribute: Submit to state stamping office and provide the insured a copy.

Typical Routing: Who Receives the Acknowledgement

Understand the common destinations so copies are delivered to the right parties for compliance and recordkeeping.

Insured Copy: Delivered to policyholder for retention and claims reference.
Broker File: Broker retains a signed copy for compliance and audit trails.
State Stamping Office: Filed if required by the state’s surplus lines reporting rules.
Carrier File: Non‑admitted insurer receives a placement copy when requested.

Digital Workflow Settings for Electronic Completion

Configure the electronic workflow to capture required data, signer authentication, and retention metadata.

Field	Configuration
Upload Method	PDF or DOCX accepted; preserve metadata
Authentication	Email + SMS code or stronger KBA as needed
Auto-fill	Use templates to populate insurer and broker fields
Notifications	Email confirmations to insured, broker, and compliance

Digital Signing and Integration Considerations

Choose an eSignature platform that supports required authentication, audit trails, and your record retention policies.

File Formats: PDF and DOCX supported
Integrations: Salesforce, NetSuite, Microsoft 365
Compliance: Audit trail and encryption at rest

Ensure the platform can export signed PDFs with a tamper-evident audit trail and integrates with your policy administration and compliance systems.

Practical Examples of How the Acknowledgement Is Used

Two concise scenarios show routine use and a compliance-focused use of the acknowledgement.

Broker Placement Example

A regional surplus lines broker places property risk with an out‑of‑state carrier whose policy begins 07/01/2026.

The broker fills insurer and premium fields, secures the insured’s electronic signature, and files the acknowledgement with the state stamping office.
The signed acknowledgement supports timely premium tax remittance, the state filing record, and provides the insured a documented disclosure of non‑admitted coverage.

Corporate Compliance Example

An insured’s compliance team reviews a package of surplus lines placements for a national roll‑up.

They require consistent acknowledgement fields and standardized tax calculations to reconcile across states.
Standardized acknowledgements streamline audits, reduce correction cycles, and create a consistent record for multi‑state premium tax filings.

Practical Tips for Accurate and Efficient Completion

Follow these best practices to reduce errors, speed processing, and maintain compliance across jurisdictions.

Standardize Templates

Use a single, centrally managed template to ensure consistent field placement, required disclosures, and tax calculation methods across brokers and offices.

Validate Names and IDs

Match insurer and broker legal names to licensing records; include license numbers to expedite regulator review and stamping acceptance.

Capture Consent

Record the insured’s consent to electronic records where ESIGN disclosure is required and preserve proof of access and assent.

Log Retention

Store signed acknowledgements with audit trails and maintain retention schedules aligned with IRS, HIPAA, and state rules.

eSignature Vendor Pricing and Feature Snapshot for Acknowledgement Workflows

Compare common pricing and feature characteristics when selecting an eSignature provider for surplus lines acknowledgement workflows. signNow is listed first per standard comparison formatting rules.

	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	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes	Yes	Yes	Yes	Varies by plan
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Varies by plan	Varies by plan	Varies by plan	Varies by plan

Frequently Asked Questions and Troubleshooting

Answers to common questions about completing, signing, and filing Insurance Surplus Lines Acknowledgements.

Need help? Contact support

Can this form be signed electronically?
Yes in most states if the signature meets ESIGN and UETA requirements: intent to sign, consent to electronic records, reliable attribution, and the ability to retain a reproducible record. Confirm any consumer disclosure obligations under 15 U.S.C. ch. 96 for consumer‑facing transactions.
Is notarization ever required?
Some states or filing processes may request notarized acknowledgements for specific placements. Check the state surplus lines office rules; where notarization is required, ensure the notary method (in‑person or RON) complies with state notary law.
What happens if the insured won’t sign?
Document attempts to obtain signature, provide the disclosure in writing, and note the refusal. Retain evidence of delivery; consult counsel if the insured’s refusal affects coverage or compliance.
How should tax be shown on the form?
Show gross premium, tax rate, and calculated tax amount clearly. If tax is pending, indicate 'To be billed' and reconcile promptly to avoid state penalties for underpayment.
Where do I file the acknowledgement?
Filing locations depend on the state: some require submission to a stamping or surplus lines reporting office, others accept electronic reporting through a designated portal; verify the destination with the state regulator.
How long must I keep the signed acknowledgement?
Retain for the life of the policy plus at least three years; for tax and HIPAA‑related records follow IRC §6501(a) and 45 CFR §164.530(j) respectively, and check for any state extensions.

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