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Insurance Surplus Lines Affidavit

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INSURANCE SURPLUS LINES AFFIDAVIT

I. Broker and Insured Identification

Broker Name:    Broker License No.:

Date of Birth / Organization Date:    Entity Type: Individual Corporation LLC Partnership Other

II. Policy and Coverage Details

Policy Number:    Policy Type:

Coverage Limit(s):    Deductible:    Premium:

Policy Period From:    To:

III. Coverage Classification (select all applicable)

Property   Casualty   Professional Liability   Marine   Aviation   Excess / Umbrella   Other:

IV. Attempts to Place with Admitted Carriers

The broker affirms that diligent efforts were made to place the insurance with admitted carriers. Complete the entries below for carriers contacted or reasons placement with admitted carriers was not feasible.

Date Contacted:    Response: Declined Insufficient limits Premium unacceptable Other   Explain:

Date Contacted:    Response: Declined Insufficient limits Premium unacceptable Other   Explain:

Date Contacted:    Response: Declined Insufficient limits Premium unacceptable Other   Explain:

V. Exclusions and Attachments

Attachments included with this affidavit (check all provided):

Declarations Page   Binder or Cover Note   Loss Runs / Claims History   Documentation of Attempts to Place with Admitted Carriers   Premium Invoice/Statement

VI. Taxes, Fees, and Remittance

Total Premium Subject to Tax:    State/Local Taxes and Fees:

Broker confirms responsibility for the collection and remittance of all applicable surplus lines taxes and fees in accordance with governing law and regulation.

VII. Affidavit and Certification

I, the undersigned, being duly sworn, state under penalty of perjury that the foregoing is true and correct. The broker has made a diligent effort to place the described insurance with authorized (admitted) insurers and documentation of those efforts is attached. The coverage has been placed with the named surplus lines insurer because admitted insurers were not reasonably available to provide the required coverage on acceptable terms. The premium, fees and taxes reported on this affidavit are accurate to the best of my knowledge and will be remitted as required by law.

Warning: False statements made herein are subject to penalties under applicable law, including civil and criminal penalties for false swearing and fraud.

Applicant / Insured Name:

Signature:

Date:

By signing above I certify that I am authorized to execute this affidavit on behalf of the named insured and that the statements contained herein are true and accurate.

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What the Insurance Surplus Lines Affidavit Is and when it’s used

An Insurance Surplus Lines Affidavit is a signed statement used by surplus lines brokers to document that coverage was placed with a nonadmitted insurer and that a diligent effort was made to obtain coverage from admitted insurers where required. The affidavit typically records broker attestations, insured and policy details, premium amounts, and state-specific stamping or filing references. It supports compliance with surplus lines rules, tax reporting, and audit trails and is retained by brokers, insurers, and sometimes state stamping offices for regulatory review.

Why this affidavit matters for compliance and auditability

The Insurance Surplus Lines Affidavit provides a documented chain of responsibility that regulators and auditors rely on to confirm lawful placement, premium reporting, and proper tax treatment. It helps prove that the broker followed state surplus lines requirements and preserves evidence critical to licensing and tax reviews.

Why this affidavit matters for compliance and auditability

Who completes and relies on the affidavit

Typical users who prepare, sign, or review surplus lines affidavits include licensed surplus lines brokers, underwriting and compliance teams, and state stamping or surplus lines offices.

  • Licensed surplus lines brokers responsible for placement decisions and attestations.
  • Insurer compliance officers who verify coverage and premium allocation.
  • State regulators and stamping offices auditing lawful placement and taxes.

Each party uses the affidavit for different purposes: brokers for recordkeeping and compliance, insurers for policy documentation, and regulators for enforcement and tax collection.

Step-by-step completion overview

Follow these core steps when preparing an affidavit to ensure completeness and regulatory alignment.

  • 01
    Prepare document: Open the correct state affidavit template and verify broker license details.
  • 02
    Enter policy data: Populate insured, insurer, policy number, period, and premium values.
  • 03
    Broker attestation: Complete the broker statement verifying diligent efforts and legal basis.
  • 04
    Sign and file: Obtain signatures, notarization if required, and submit per state rules.

How to configure an online affidavit workflow

Key workflow settings let you collect signatures, set authentication, and route completed affidavits to the right recipients automatically.

Field Configuration
Signature field Require signer name, signature, and date.
Authentication Use email plus SMS code or ID verification for higher assurance.
Routing Auto-send copies to broker, insurer, and state stamping office.
Retention Save completed PDF and audit trail to secure storage.

Typical submission and filing flow

A clear routing path reduces processing time and ensures each party receives required documentation.

  • Broker completes: Broker fills affidavit, attaches policy documents, and initiates signing.
  • Signer authenticates: Insured or authorized officer authenticates and signs electronically or with a notary.
  • File with state: Submit to state stamping office or follow state electronic filing requirements.
  • Store records: Archive signed affidavit, audit trail, and supporting documents for retention.

Digital signing requirements and integrations

Choose a platform that supports required authentication, audit trails, and the file formats your state accepts.

  • File formats: PDF and Word DOCX are widely accepted for affidavit uploads.
  • Integrations: Connectors for Salesforce, NetSuite, Google Workspace, and Box streamline routing.
  • Authentication: Support for email, SMS, KBA, and identity document checks improves signer attribution.

Ensure the platform you select can produce a tamper-evident PDF, maintain an audit trail, and support any state RON or notarization workflows that apply.

Common timing expectations and filing windows

Deadlines vary by state and by whether a stamping office or tax filing is required; confirm the exact timeframe with the applicable state office.

Policy effective timing:

Affidavit is commonly completed when coverage is bound or issued.

State filing window:

Many states require filing within 30–90 days of binding; check the state rule.

Tax reporting:

Premium allocation may influence state tax returns and reporting deadlines.

Notarization timeframe:

If notarization is required, sign and notarize before filing or stamping.

Record retention deadline:

Keep records long enough to satisfy state audits and federal retention rules.

Key processing milestones from placement to archive

Track these stages to ensure the affidavit and related documents move through the required compliance checkpoints.

01

Placement recorded

Broker documents placement details and prepares affidavit for signature.

02

Signatures obtained

Authorized signers and any required notary complete the affidavit.

03

State filing/stamping

Affidavit submitted to stamping office or filed per state rules.

04

Long-term retention

Completed files archived to meet audit and retention requirements.

Common preparation errors to avoid

  • Using inconsistent legal names between policy and affidavit increases audit risk.
  • Omitting broker license numbers can trigger noncompliance findings.
  • Failing to notarize when required invalidates the affidavit in some states.
  • Not retaining the audit trail makes electronic signatures harder to defend.

Potential penalties and regulatory risks

Fines and sanctions: Civil fines and administrative penalties
Tax exposure: Incorrect premium reporting can trigger tax assessments
Coverage disputes: Improper affidavit may lead to challenges to coverage validity
License risk: Broker disciplinary action for noncompliance
Audit findings: State audits may require repayment or corrective filings
Legal costs: Defense and remediation expenses from enforcement actions

Essential affidavit data elements at-a-glance

Insured: Full legal name
Insurer: Carrier name and identifier
Policy details: Number, period, coverage
Premiums: Gross and net amounts
Broker: License number and state
Signature: Signer name, title, date

Representative eSignature vendor pricing and features

Compare baseline pricing and core capabilities for common eSignature vendors. Confirm plan details with each vendor before purchase.

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 (Business Premium) Plan-dependent Plan-dependent Available Plan-dependent
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Varies by plan/BAA Varies by plan/BAA Varies Varies

Core elements a professional affidavit contains

A complete affidavit combines administrative data, attestations, and authentication elements so regulators can verify lawful surplus lines placement.

Title

Clear form title identifying the document as an Insurance Surplus Lines Affidavit and the issuing state or stamping office.

Broker attestation

A signed statement by the broker confirming diligent efforts to find admitted market placement where applicable.

Insurer details

Nonadmitted insurer legal name, identifier, and jurisdiction of domicile for regulatory identification.

Policy specifics

Policy number, coverage description, limits, deductibles, and effective dates tying the affidavit to the contract.

Premium breakdown

Gross and net premium, fees, and any taxes or stamping fees assessed on the transaction.

Authentication

Signature, title, date, and notarization or RON evidence plus an audit trail for electronic execution.

Practical tips for accurate and efficient completion

Adopt consistent templates and digital workflows to reduce errors, speed processing, and meet regulatory requirements.

Use a validated template
Standardize a state-specific affidavit template to reduce omissions and ensure inclusion of required attestations and fields.
Verify names and numbers
Match insured, insurer, and broker names and license numbers to official records to avoid audit discrepancies.
Capture complete audit trails
Preserve timestamps, IP addresses, and signer authentication details when using eSignature to support legal admissibility.
Check state rules before filing
Confirm notarization, RON, stamping, and filing windows with the applicable state surplus lines office.

Practical examples of affidavit use

These two scenarios illustrate how affidavits are used in common surplus lines placements and audits.

Specialty Coverage Placement

A mid-market broker places unique cyber coverage on the surplus lines market

  • Broker completes affidavit documenting admitted market decline
  • State audit accepted the affidavit and premium allocation, avoiding penalties after prompt filing and complete supporting documents.

Large Commercial Risk

An international insured requires excess casualty limits unavailable in admitted market

  • Broker records diligent effort and premium details in the affidavit
  • The insurer and lender received the stamped affidavit and the client satisfied collateral requirements for closing.

Frequently asked questions about affidavits and e-signatures

Answers to common legal, technical, and filing questions when working with Insurance Surplus Lines Affidavits.


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