Are electronic signatures legally valid?

Yes. Electronic signatures are legally enforceable under the federal ESIGN Act (15 U.S.C. ch. 96) and state UETA statutes where adopted, provided the transaction meets intent, consent, attribution, and record-retention requirements. Confirm any exception (wills, certain court filings) before proceeding.

When must the disclosure be filed?

Filing deadlines vary by state and by insurer type; many jurisdictions require timely submission to the state stamping office or surplus lines regulator upon placement. Consult the state surplus lines or insurance department for exact timelines and any stamping fee payment schedules.

Who is required to sign the disclosure?

Typically the named insured or an authorized representative signs the disclosure; the surplus lines broker signs where required by jurisdiction. Ensure the signer’s role is recorded and that electronic consent is captured per ESIGN/UETA to support enforceability.

Is notarization or witnesses required?

Most surplus lines disclosures do not require notarization, but some states may have specific witness or notarization rules for related documents. Remote Online Notarization (RON) may be acceptable where authorized; verify state notary regulations before using RON.

How do I correct a submitted disclosure?

If information submitted to the stamping office is incorrect, submit an amended disclosure or contact the regulator according to state procedures. Keep copies of both original and amended filings, and document the reason for amendment for audit purposes.

How long should I retain executed disclosures?

Retain executed disclosures for the policy term plus at least three years; follow federal IRS guidance (IRC §6501(a)) and industry-specific periods such as HIPAA six-year requirements. Check state rules for longer mandatory retention periods.

Electronic Signature
Templates
Legal
Surplus Lines Disclosure Agreement

Surplus Lines Disclosure Agreement

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SURPLUS LINES DISCLOSURE AGREEMENT

This Surplus Lines Disclosure Agreement (the "Agreement") is entered into as of Effective Date: by and between Insured Name: whose address is ("Insured"), and Surplus Lines Broker Name: whose address is ("Broker").

RECITALS

WHEREAS, Insured has requested that Broker procure insurance coverage for certain risks identified below and presented to Broker for placement in the surplus lines market; and

WHEREAS, Broker is licensed to place surplus lines insurance in the jurisdiction of placement and represents that the proposed insurer is a non-admitted insurer not authorized to write insurance in the state of placement and that placement with such insurer is permitted under applicable surplus lines laws and regulations of the state of placement; and

WHEREAS, Insured acknowledges that surplus lines insurance may not be covered by state guaranty funds and that certain taxes, fees, and filing obligations may be required in connection with such placement.

NOW, THEREFORE, in consideration of the mutual covenants contained herein, the parties agree as follows:

1. POLICY AND PLACEMENT

1.1 Policy Information. The insurance placed pursuant to this Agreement is described as follows:

Insurer (Non-Admitted): Policy Number:

Policy Period - From:

Policy Period - To:

Coverage Description:

2. DISCLOSURE

2.1 Non-Admitted Insurer. Insured acknowledges and agrees that the insurer identified above is not licensed or admitted in the state of placement and, as a consequence, claims against the insurer are not covered by any state insurance guaranty fund or similar insolvency protection.

2.2 Taxes, Fees and Filings. Broker will calculate and, where required by law, collect or remit applicable premium taxes, stamping fees, and surplus lines filing fees related to the placement. Insured shall be responsible for payment of premium, taxes, fees, and charges specified on the invoice or billing document issued in connection with the policy, subject to the terms of the policy and this Agreement.

State of Placement:

3. INSURED ACKNOWLEDGMENTS AND REPRESENTATIONS

3.1 Acknowledgment. Insured acknowledges receipt of the disclosure that the insurer is non-admitted and that state guaranty fund protection does not apply. Insured further acknowledges that the decision to accept surplus lines coverage is made with full knowledge of those facts.

3.2 Representations. Insured represents and warrants that all information supplied to Broker for the purpose of procurement, underwriting, quotation, or placement is true, complete, and accurate. Insured agrees to promptly provide any additional information reasonably requested by Broker or insurer in connection with underwriting or claims handling.

Insured acknowledges that coverage is placed with a non-admitted insurer and that state guaranty fund protection is not available.

4. BROKER DUTIES; FILINGS

4.1 Broker Duty. Broker agrees to exercise reasonable professional skill and care in seeking placement, to use commercially reasonable efforts to procure the insurance described herein, and to make such surplus lines filings as required by the laws and regulations of the state of placement.

4.2 Filings and Affidavits. Broker will prepare and submit required surplus lines affidavits and any required notices or filings to the appropriate authorities. Broker shall provide Insured with copies of material filings and affidavits upon request or when such documents are required by law to be provided to Insured.

5. PREMIUM, TAXES AND PAYMENT

Total Premium:

5.1 Payment. Insured shall pay premium, applicable taxes and fees as invoiced by Broker in accordance with the payment terms set forth on Broker's invoice. Late payment shall be subject to interest and collection costs as permitted by applicable law.

6. INDEMNIFICATION

6.1 Indemnity by Insured. Insured shall indemnify, defend and hold harmless Broker and its employees, agents and affiliates from and against any and all losses, liabilities, claims, costs and expenses (including reasonable attorneys' fees) arising out of Insured's misrepresentation, breach of this Agreement, failure to pay premium, or willful misconduct in connection with the placement of the insurance described herein.

7. CONFIDENTIALITY

7.1 Confidential Information. Each party agrees that information exchanged in connection with the placement of coverage, including underwriting information and pricing, shall be treated as confidential and shall not be disclosed to third parties except as required by law, regulation, or as necessary to effectuate the placement or service the policy.

8. NOTICES

8.1 Notices. All notices required or permitted under this Agreement shall be in writing and delivered to the contact information set forth below or to such other address as a party may designate by notice in accordance with this section.

Insured Notice Contact: Broker Notice Contact:

9. AMENDMENTS; WAIVER; COUNTERPARTS

9.1 Amendments. No amendment, modification or waiver of any provision of this Agreement shall be effective unless in writing and signed by both parties.

9.2 Waiver. The failure of either party to enforce any provision of this Agreement shall not be construed as a waiver of such provision or the right to enforce it at a later time.

9.3 Counterparts. This Agreement may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one and the same instrument. Facsimile, electronic image, or other electronic signatures shall be treated as original signatures.

10. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

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

10.2 Entire Agreement. This Agreement, together with any endorsements, binders, affidavits, or invoices incorporated by reference, 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 oral or written.

10.3 Severability. If any provision of this Agreement is held to be invalid or unenforceable by a court of competent jurisdiction, the remainder of this Agreement shall continue in full force and effect and the invalid or unenforceable provision shall be reformed only to the extent necessary to make it valid and enforceable while preserving the parties' original intent.

11. MISCELLANEOUS

11.1 Survival. Provisions of this Agreement which by their nature are intended to survive termination or expiration of this Agreement shall so survive, including but not limited to indemnity, confidentiality, and payment obligations.

Additional Terms or Instructions:

By signing below, the parties acknowledge that they have read and understood this Agreement, that they have authority to enter into this Agreement, and that they accept the terms and disclosures contained herein.

Insured:

By:

Date:

Surplus Lines Broker:

By:

Date:

What the Surplus Lines Disclosure Agreement Is

The Surplus Lines Disclosure Agreement is a formal document used by surplus lines brokers to notify insureds when coverage is placed with an insurer not licensed in the insured’s state. It explains the carrier’s nonadmitted status, applicable taxes or fees, and broker contact information. The form records the insured’s acknowledgment and helps meet state surplus lines reporting requirements. Although formats vary by jurisdiction, the core purpose is consumer notice and regulatory traceability; properly completed disclosures support compliance with state surplus lines laws and reduce exposure to licensing and premium tax disputes.

Why Accurate Disclosures Matter

Use a Surplus Lines Disclosure Agreement to provide clear notice when coverage is placed with a nonadmitted insurer, document insured consent, and create an auditable record for state reporting. Proper disclosure reduces regulatory risk and supports accurate premium tax and stamping fee accounting.

Who Prepares and Signs These Agreements

Typical users include surplus lines brokers, wholesale agents, carriers, and compliance staff who prepare or review surplus lines disclosures.

Surplus lines brokers — complete and file with state stamping office as required, and deliver to insured promptly.
Wholesale brokers — coordinate carrier placement details and confirm insured acknowledgment and signature on the disclosure.
Carriers and underwriters — verify broker disclosures for tax reporting and regulatory audits.

The completed agreement is shared with the insured and retained by the broker for filing, audit, and tax-reporting purposes as required by state rules.

Step-by-Step: Completing the Disclosure

Follow these steps to complete and deliver a Surplus Lines Disclosure Agreement accurately for filing and insured acknowledgement.

01

Prepare: Gather policy, carrier, and broker license information.
02

Populate: Enter required fields and check jurisdiction-specific boxes.
03

Obtain Signature: Secure insured signature and date using accepted method.
04

File: Submit to state stamping office or retain per state rules.

Typical Workflow from Preparation to Filing

Typical flow: broker completes the disclosure, obtains insured signature, and files or transmits records to the stamping office.

Broker fills: Populate form fields with carrier and insured details.
Sign: Insured signs electronically or on paper, method recorded.
Transmit: Send copy to stamping office and retain broker copy.
Audit Trail: Maintain proof of delivery, signature timestamp, and attachments.

Configuring an Electronic Disclosure Workflow

Configure an electronic workflow to capture required fields, signer authentication, and automatic distribution to regulators or internal repositories.

Field	Configuration
Signer Authentication	Email link with optional SMS code for identity.
Conditional Fields	Show state-specific disclosures based on insured location.
Routing	Auto-send signed copy to stamping office and broker archive.
Retention	Store signed PDF with metadata for audit trail.

Platform and Integration Considerations

Use eSignature platforms that support PDF, Word, and API integrations; select options that meet state authentication requirements.

File Formats: PDF, DOCX, and flattened copies supported.
Integrations: Salesforce, NetSuite, Google Workspace available.
Authentication: Email, SMS, KBA, and SSO options.

Core Elements to Include in the Disclosure

A professional Surplus Lines Disclosure Agreement should clearly state carrier status, tax and fee responsibilities, broker identity, insured acceptance, applicable jurisdiction, and signature authentication to support regulatory review.

Carrier Status

Describe that the insurer is 'nonadmitted' or 'surplus lines' in the insured's state, include the insurer's domicile and NAIC code where available, and state how this affects guaranty fund protections and regulatory oversight.

Taxes & Fees

Itemize any premium taxes, stamping fees, or regulatory surcharges charged to the insured or collected by the broker; specify payment responsibility, calculation method, and relevant state statute citations.

Broker Information

Include broker name, full mailing address, license number and state, contact phone and email, and a declaration of broker role in placement and premium handling for audit purposes.

Insured Acknowledgment

Provide clear language the insured can read and initial or sign to confirm understanding that the carrier is nonadmitted and that different protections or remedies may apply compared with admitted insurers.

Policy Details

List policy number, policy period, limits, endorsements, and any underwriting notes necessary to match the disclosure to the operative insurance contract and claims handling processes.

Signature & Auth

Specify acceptable signature methods, date of signing, signer role (named insured, authorized representative), and any notarization or witness requirements per state law, plus retention instructions for the executed document.

Essential Fields to Capture

Insured Name: Full legal name as on policy.

Insurer Details: Legal name, domicile, NAIC code.

Policy Data: Policy number, period, limits, endorsements.

Tax Information: Premium tax and stamping fee amounts.

Broker License: Broker name and license number.

Signature Block: Signer name, role, date, and method.

Penalties and Risks of Incomplete or Incorrect Disclosures

Regulatory Penalties: Fines or cease-and-desist orders.

Tax Exposure: Incorrect premium tax reporting.

Contract Voidance: Coverage disputes or unenforceability.

Delayed Claims: Claim payments can be delayed.

Audit Findings: Record-keeping failures noted by regulator.

Reputational Harm: Loss of client trust and referrals.

Common Errors to Avoid

Failing to indicate carrier nonadmitted status clearly, which can leave insureds uninformed and expose the broker to regulator inquiries and corrective action.
Entering mismatched names, policy numbers, or dates that prevent state stamping or cause rejection during filing, prolonging compliance timelines.
Omitting required tax or stamping fee calculations or failing to note which party pays them, which may trigger underpayment penalties.
Using noncompliant signature methods without recording consent or audit data, weakening enforceability under ESIGN and state law.

Practical Examples from Brokerage Operations

Real-world examples show how accurate surplus lines disclosures streamline compliance and reduce audit risk for brokers and carriers.

Martin Properties

Martin Properties used eSign to deliver surplus lines disclosures remotely during property closings, eliminating in-person signature delays.

Signatures returned same day, speeding transactions.
The firm retained complete audit trails for every disclosure, which simplified state stamping submissions and reduced follow-up inquiries. Using standardized disclosure templates also decreased administrative overhead and improved consistency across multiple brokerage offices.

BIS

BIS integrated eSignature into surplus lines workflows to centralize disclosures and enforce consistent broker attestations across regions.

Centralized records reduced audit response time.
Automated routing sent completed disclosures to regulatory contacts and internal compliance, allowing the team to meet stamping deadlines reliably. The change also lowered document handling errors and provided searchable records for future examinations.

Comparing eSignature Pricing and Core Capabilities

Compare baseline pricing and core features for eSignature platforms commonly used to execute Surplus Lines Disclosure Agreement documents electronically.

	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	Yes	Yes	Yes	Yes
Bulk Send	Yes (Premium)	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

FAQs: Common Questions on Disclosures and Electronic Signing

Answers to common questions about completing, signing, filing, and correcting Surplus Lines Disclosure Agreements in the United States.

Need help? Contact support

Are electronic signatures legally valid?
Yes. Electronic signatures are legally enforceable under the federal ESIGN Act (15 U.S.C. ch. 96) and state UETA statutes where adopted, provided the transaction meets intent, consent, attribution, and record-retention requirements. Confirm any exception (wills, certain court filings) before proceeding.
When must the disclosure be filed?
Filing deadlines vary by state and by insurer type; many jurisdictions require timely submission to the state stamping office or surplus lines regulator upon placement. Consult the state surplus lines or insurance department for exact timelines and any stamping fee payment schedules.
Who is required to sign the disclosure?
Typically the named insured or an authorized representative signs the disclosure; the surplus lines broker signs where required by jurisdiction. Ensure the signer’s role is recorded and that electronic consent is captured per ESIGN/UETA to support enforceability.
Is notarization or witnesses required?
Most surplus lines disclosures do not require notarization, but some states may have specific witness or notarization rules for related documents. Remote Online Notarization (RON) may be acceptable where authorized; verify state notary regulations before using RON.
How do I correct a submitted disclosure?
If information submitted to the stamping office is incorrect, submit an amended disclosure or contact the regulator according to state procedures. Keep copies of both original and amended filings, and document the reason for amendment for audit purposes.
How long should I retain executed disclosures?
Retain executed disclosures for the policy term plus at least three years; follow federal IRS guidance (IRC §6501(a)) and industry-specific periods such as HIPAA six-year requirements. Check state rules for longer mandatory retention periods.

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