Surplus Line Insurance Document

SURPLUS LINE INSURANCE PLACEMENT AGREEMENT

This Surplus Line Insurance Placement Agreement (the Agreement) is made as of Month Day Year by and between Insured Name: (the "Insured") and Surplus Lines Broker Name: (the "Broker").

RECITALS

WHEREAS, the Insured desires to obtain insurance coverage for the risk described below from a nonadmitted insurer authorized solely through surplus lines placement; and

WHEREAS, the Broker is duly licensed or qualified to place surplus lines coverage and has represented that it has the authority to place insurance with nonadmitted insurers consistent with applicable surplus lines laws and regulations; and

WHEREAS, the parties desire to set forth their respective rights and obligations with respect to the placement and administration of the surplus lines policy described below.

NOW, THEREFORE

In consideration of the mutual covenants set forth herein and other good and valuable consideration, the receipt and sufficiency of which are acknowledged, the parties agree as follows:

1. POLICY AND RISK DETAILS

Nonadmitted Insurer Name:

Policy Number: Coverage Description:

Limits of Liability:

Effective Date: Month Day Year     Expiration Date: Month Day Year

2. AUTHORITY AND PLACEMENT

The Insured hereby engages the Broker and grants the Broker full authority to negotiate, procure and effect the surplus lines coverage described above on behalf of the Insured. Broker's authority includes signing documents necessary to place coverage, procuring rates and terms, and arranging payment of premium and related charges. Broker shall act as the Insured's agent solely for the purpose of placement of the insurance described herein.

3. PREMIUM, FEES, TAXES AND PAYMENT

Premium (Gross): Broker Fee: Taxes and Fees (state & surplus lines):

Total Due to Broker:

Payment Terms: The Insured shall remit payment to the Broker in accordance with invoices issued by the Broker. Failure to pay premium, fees or taxes when due shall entitle Broker to suspend further services, cancel placement efforts, or pursue collection consistent with applicable law.

4. COMPLIANCE WITH SURPLUS LINES LAW

Broker represents and warrants that it will exercise reasonable diligence to comply with all applicable surplus lines placement statutes, rules and filing requirements of the jurisdiction of placement, including necessary affidavits, filings and payment of surplus lines taxes and fees. Broker shall provide to the Insured, upon request, documentation of placement efforts, state filings, and a surplus lines placement affidavit.

State of Placement: Affidavit / Certificate Number: Certificate Issued:

5. REPRESENTATIONS AND WARRANTIES

Broker warrants that it is duly licensed where required to perform the services described herein and that it will act in good faith in procuring the described coverage. Broker makes no warranty as to the financial condition of the nonadmitted insurer, but will disclose to the Insured any material information known to Broker that would affect Insured's decision to accept coverage.

The Insured represents that all material facts and circumstances known to the Insured have been disclosed to the Broker and that premiums and payments will be made in accordance with the terms of this Agreement and applicable invoices.

6. INDEMNITY; LIMITATION OF LIABILITY

The Insured shall indemnify, defend and hold harmless the Broker and its officers, employees and agents from and against all claims, liabilities, losses, fines, penalties and expenses (including reasonable attorneys' fees) arising out of (a) the Insured's failure to pay premium, fees or taxes; (b) material misrepresentations by the Insured; or (c) the Insured's breach of this Agreement. Broker's liability for any claim arising out of this Agreement shall be limited to direct damages and shall not include punitive, consequential or incidental damages.

7. RECORDS AND AUDIT

Broker shall maintain records supporting placement decisions, filings and premium accounting for a period of not less than five (5) years and shall provide such records to the Insured or regulators upon lawful request. Broker shall permit reasonable inspection and audit of relevant records by the Insured or its authorized representatives on prior written notice and during normal business hours.

8. CONFIDENTIALITY

Except as required by law or regulatory obligation, each party shall keep confidential all nonpublic information furnished by the other party in connection with this Agreement and shall not disclose such information to third parties without prior written consent.

9. NOTICES

All notices required or permitted hereunder shall be in writing and shall be deemed given when delivered in person, sent by certified mail with return receipt requested, or sent by nationally recognized overnight courier, to the address set forth above or to such other address as either party may designate by notice to the other.

10. AMENDMENT; WAIVER

No amendment, modification or waiver of any provision of this Agreement shall be effective unless set forth in a written instrument signed by both parties. The failure of either party to enforce any right or remedy shall not constitute a waiver of that right or remedy nor of any other rights or remedies.

11. GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the State of without regard to conflict of laws principles.

12. ENTIRE AGREEMENT

This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, proposals and communications, whether written or oral.

13. SEVERABILITY

If any provision of this Agreement is held invalid or unenforceable by a court of competent jurisdiction, the remainder of this Agreement shall continue in full force and effect and such provision shall be reformed to the minimum extent necessary to render it enforceable.

14. COUNTERPARTS; ELECTRONIC SIGNATURES

This Agreement may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument. Signatures transmitted by electronic means shall be deemed originals and binding for all purposes.

15. MISCELLANEOUS

The parties acknowledge that Broker may place coverage with nonadmitted insurers, and that such placements may not be subject to the guarantee funds or guaranty associations of the State of placement. Broker shall notify Insured of any known changes in the insurer's status that materially affect the Insured's coverage.

Sign Now