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Insurance Surplus Lines Disclosure

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INSURANCE SURPLUS LINES DISCLOSURE

This Surplus Lines Disclosure (the Disclosure) provides notice that the insurance described in this document has been placed with a surplus lines insurer that is not licensed or admitted in the state of placement. The undersigned applicant acknowledges receipt of this Disclosure and understands the coverage, limitations and financial differences associated with surplus lines placement.

Applicant / Insured Information

Insured Name:

Producer / Broker Information

Surplus Lines Insurer & Policy Details

Insurer Name:

Policy Period: From to

Limit of Insurance: Deductible:

Reason(s) for Placement in Surplus Lines Market

The producer attests that the following reason(s) support placement with a surplus lines insurer (check all that apply):

Coverage Summary and Exclusions

Loss Payee / Beneficiary (if applicable)

Applicant Acknowledgment and Certification

By signing below, the Applicant acknowledges and agrees that:

  1. The insurer identified above is not licensed or admitted in the state where this Disclosure is executed and therefore the policy is not protected by the state insurance guaranty fund or association;
  2. The Producer has represented that reasonable efforts were made to place the coverage with admitted insurers, but placement in the surplus lines market was necessary for the reasons indicated on this form;
  3. The Applicant is responsible for any applicable surplus lines taxes, stamping fees, or other surcharges unless otherwise provided by law or agreement; and
  4. The Applicant has read and understands the principal coverage terms and exclusions disclosed above and accepts the financial and regulatory differences associated with surplus lines placement.

Applicant Signature

Print Name:

Signature:

Date:

The signature above certifies under penalty of perjury that the information provided on this Disclosure is true, accurate and complete to the best of the signer's knowledge, and that the signer has authority to bind the Applicant.

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Understanding the Insurance Surplus Lines Disclosure

An Insurance Surplus Lines Disclosure is a written notice provided when coverage is placed with a non-admitted (surplus or excess) insurer. It explains to the policyholder that the insurer is not licensed in the insured’s state, describes coverage limits and conditions, and typically documents broker attestations and applicable surplus lines taxes and fees. States require a surplus lines disclosure so consumers understand placement outside the admitted market and to enable stamping office filings and premium tax reporting to the appropriate state authority.

Why this disclosure matters and its legal footing

The disclosure protects consumer notice rights, supports compliance with state surplus lines statutes, and creates an auditable record for premium tax and stamping office filings. Electronic execution is generally permissible under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and retention requirements are met.

Why this disclosure matters and its legal footing

Who prepares and receives the surplus lines disclosure

Brokers and surplus lines producers prepare the disclosure; multiple parties rely on it for tax, compliance, and coverage verification.

  • Surplus lines broker or producer: prepares disclosure and submits stamping copy to the state stamping office or designated filer.
  • Policyholder or insured: receives the consumer notice and retains a copy for coverage and tax records.
  • Surplus lines carrier and stamping office: use the disclosure to calculate premium tax and confirm lawful placement.

Retain proof of delivery and execution; regulators and auditors will expect a clear record of who received and signed the disclosure.

Essential parts of a professional surplus lines disclosure

A complete disclosure combines identification, placement details, tax and fee information, broker attestations, and signature blocks so regulators and insureds can confirm the legal basis and financial obligations of the placement.

Insured Details

Full insured name, address, and policyholder contact information so the disclosure clearly identifies who the notice covers and where records should be kept.

Insurer Identification

Name of the surplus lines (non-admitted) insurer, domicile or jurisdiction, and any carrier identification numbers required by state stamping offices.

Coverage Summary

Policy type, limits, effective and expiration dates, and a concise description of coverages placed with a non-admitted carrier.

Premiums & Fees

Premium amount, any applicable surplus lines premium taxes, and stamping office fees with instructions on who is responsible for payment.

Broker Attestation

Producer statement that admitted market options were unavailable or insufficient and that the placement complies with state surplus lines laws.

Signature & Date

Signature block for insured and broker, date of acknowledgement, and space for electronic signature metadata or notarization when required.

Core information fields to include

Insured name: Full legal name
Policy number: Carrier policy ID
Coverage period: Effective–expiry dates
Premium amount: Total premium
Broker license: Producer name and license
Signature details: Signer name and date

Step-by-step: completing and delivering the disclosure

Follow these sequential steps to create, execute, and file the Insurance Surplus Lines Disclosure correctly.

  • 01
    Prepare: Assemble policy and premium details.
  • 02
    Draft: Populate disclosure template fields accurately.
  • 03
    Execute: Obtain signatures and notarization where required.
  • 04
    File: Submit to insured and stamping office per state rules.

Configuring an online disclosure workflow

Set up digital templates and automation so disclosures are consistent, auditable, and delivered to all required parties.

Field Configuration
Template Create reusable disclosure template with locked fields
Delivery Method Email link and optional secure portal
Signer Authentication Email+SMS OTP or KBA where required
Audit Trail Enable metadata capture and attachment of stamping receipts

Typical routing for completed disclosures

A clear routing path ensures each stakeholder receives the disclosure and the stamping office receives required filings.

  • Broker to Insured: Deliver disclosure to insured at placement
  • Broker to Stamping Office: File with state stamping office per jurisdictional rules
  • Broker to Carrier: Send copy to surplus lines carrier for policy record
  • Archive: Store executed copy for compliance and audit

Technical considerations for digital delivery and signing

Ensure your eSignature platform supports required formats, integrations, and security features for regulatory filings.

  • File formats: PDF, DOCX supported
  • Integrations: Salesforce, NetSuite, Google Workspace
  • Security: TLS 1.2/1.3 and AES-256

Use a solution that captures an audit trail, preserves exact signed PDFs, and supports bulk send or API integrations for stamping office workflows.

Timing expectations and common filing windows

Timely delivery and filing are critical; state rules determine exact windows for disclosure delivery to insureds and stamping office filings.

Delivery to insured:

At or before coverage inception

Stamper filing window:

Varies by state; often 30–90 days after placement

Premium tax payment:

Due per state schedule when filing

Record retention start:

From effective date of policy

Amendments:

File endorsements within state timelines

Common mistakes to avoid when preparing the disclosure

  • Incomplete insured or broker details leading to rejected stamping office filings and delayed tax accounting.
  • Incorrect premium or fee calculations that cause tax underpayment or audit adjustments by state authorities.
  • Missing or unsigned broker attestation that invalidates the placement under state surplus lines rules.
  • Attempting to rely on a generic disclosure template that does not reflect state-specific statutory language.

Potential penalties and compliance risks

Late filing fines: State fines and interest
Tax assessment: Audited premium tax due
Coverage disputes: Insured may contest claim handling
Broker sanctions: License suspension or fines
Invalid placement: Placement may be deemed noncompliant
Privacy breach: HIPAA or data protection exposure

Real-world examples of disclosure usage

These short examples show how organizations use surplus lines disclosures to document non-admitted placements and support regulatory filings.

Martin Properties

A regional property manager placed coverage with a surplus lines carrier when admitted limits were insufficient.

  • Broker captured insured acknowledgment electronically using an audit trail.
  • The executed disclosure plus stamping receipt provided a complete file for lender requirements and subsequent audits, and the company retained records per its document retention policy.

Xerox (NetSuite Ops)

A corporate risk team put complex specialty coverage on surplus lines after market exhaustion.

  • The broker attached a premium tax calculation summary.
  • The disclosure, integrated into NetSuite, automates bookkeeping entries and supplies the stamping office submission history during regulatory review.

Practical tips for accurate and efficient completion

Adopt standardized templates, verify state rules before filing, and capture a durable audit trail to reduce rework and regulatory exposure.

Use standardized templates
Maintain a vetted template that includes required state-specific language and locked fields to prevent accidental edits and ensure consistent filings across producers.
Verify broker licensure
Confirm producer license numbers and states before filing; inaccurate licensure details can invalidate a placement and trigger penalties.
Capture audit metadata
Record IP, timestamp, and signer authentication method for each signature to support enforceability under ESIGN (15 U.S.C. ch. 96) and state law.
Coordinate tax remittance
Align stamping office filings with premium tax payment schedules to avoid late fees and interest assessments from state authorities.

How the surplus lines disclosure differs from related documents

Compare common document types to understand when a surplus lines disclosure is required versus other insurance records.

Document Type Purpose Typical Timing
Surplus Lines Disclosure notice of non-admitted placement at placement
Certificate of Insurance proof of coverage summary on request or issuance
Admitted Market Disclosure policy from licensed carrier at issuance
Binder Agreement temporary coverage confirmation pre-policy

eSignature vendor comparison for managing surplus lines disclosures

Compare baseline vendor pricing and capabilities relevant to executing and storing Insurance Surplus Lines Disclosures; signNow is listed first per platform comparison guidance.

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 No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently asked questions and troubleshooting

Answers to common questions about completing, executing, and filing the Insurance Surplus Lines Disclosure.


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