Surplus Lines Insurance Forms

SURPLUS LINES INSURANCE FORMS

Producer / Broker Information

Insured / Applicant Information

Insured Name:

Contact Phone:    Email:

Date of Birth (if individual):    Tax ID / SSN:

Policy Details

Insurer Name (Non-admitted):

Policy Type: Property Casualty Professional Liability Cyber

Coverage Limit: $    Deductible: $    Annual Premium: $

Policy Period From:    To:

Coverage Options & Limits

Select coverages requested (check all that apply):

Property - All Risk    Limit: $

General Liability    Limit: $

Professional Liability    Limit: $

Exclusions and Acknowledgments

The following exclusions are standard to placement with surplus lines insurers. The insured acknowledges receipt and review of exclusion language and accepts responsibility to review the policy text upon issuance.

Exclusion — War, hostilities, and nuclear hazard    Exclusion — Pollution and contamination

Exclusion — Intentional acts and fraudulent acts    Exclusion — Specific cyber exclusions (where applicable)

Beneficiary / Additional Insured / Mortgagee

Relationship:    Allocation %:

Prior Claims / Loss History

Have there been any claims, suits, or losses in the past five years?   Yes    No

Surplus Lines Disclosure & Taxes

By placing coverage with a non-admitted (surplus lines) insurer the insured acknowledges that the insurer is not a member of any state guaranty fund. The insured understands there may be different solvency protections than those afforded by admitted insurers and accepts the risks associated with non-admitted placement.

The insured acknowledges that applicable surplus lines taxes, stamping fees, and other regulatory assessments may apply to this placement and that such amounts are the insured's responsibility. Estimated taxes/fees: $

I acknowledge receipt of surplus lines disclosure and the tax/fee notice.

Authorization, Representation and Certification

The undersigned certifies that the statements and particulars contained in this form are true and complete to the best of the undersigned's knowledge. The undersigned authorizes the broker and any appointed representative to obtain and disclose underwriting, claims, loss history, and credit information necessary to effect placement. The undersigned understands that any material misrepresentation or omission may be a basis for rescission or denial of coverage and may be subject to penalties under applicable law.

Fraud Warning: Where applicable, false statements or omissions made with intent to defraud may constitute a criminal offense. The undersigned acknowledges receipt of this fraud warning as required by law.

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