Surplus Lines Acknowledgement
For Specific States:
Risk Location in Connecticut – I/We, the named insured, state on the date of this purchase, I/We directed the licensed producing agent named on this Surplus Lines Statement to obtain insurance coverage described herein; that I/We were informed by said producing agent that he/she made a diligent effort to place this risk with licensed insurers authorized to transact the class of insurance involved and which accept in the usual course of business, insurance on risks of the same class as the risk described herein; and that said companies accepted only part of or no part of the required insurance. I/We, were further informed by said producing agent that the amount of insurance indicated herein could be obtained from certain insurers not licensed to transact business in the State of Connecticut. I/We therefore directed the producing agent named herein to obtain said insurance though the office of the licensed Surplus Lines Broker named herein. I/We have been advised by the producing agent named herein that such insurance represents only the excess over the amounts procurable from licensed insurers or the Connecticut residual market.
Risk Location in Florida – At my direction Professional Services Purchasing Group has placed my coverage in the surplus lines market. As required by Florida Statute 626.916, I have agreed to this placement. I understand that superior coverage may be available in the admitted market and at a lesser cost and that persons insured by surplus lines carriers are not protected by the Florida Insurance Guaranty Association with respect to any right of recovery for the obligation of an insolvent unlicensed insurer. I further understand the policy forms, conditions, premiums, and deductibles used by surplus lines insurers may be diﬀerent from those found in policies used in the admitted market. I have been advised to carefully read the entire policy.
Risk Location in North Carolina – I, the undersigned, have been unable to purchase insurance from any insurance company licensed to do business in North Carolina: therefore, application is made under Article 21 of Chapter 58 of the General Statutes of North Carolina to procure insurance through an insurance company that is not licensed in North Carolina. I understand that risks in this State may be insured in insurance companies not licensed to do business in North Carolina only to the extent that such risk(s) cannot be insured in companies licensed to do business in North Carolina under any policy form filed with and approved by the Commissioner of Insurance. I further understand that the insurance company with which this coverage has been placed is not licensed by the State of North Carolina and is not subject to its supervision, and that in the event of the insolvency of the insurance company, losses under this policy will not be paid by any State insurance guaranty or solvency fund.
For other States – I acknowledge that this contract is registered and delivered as a surplus line coverage under the Surplus Line Insurance Law of the state of the risk location.
Terms and Conditions