Fillable Surplus Lines Statement (Form SL-8) (James Allen Insurance)

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Surplus Lines Statement (Form SL-8) (James Allen Insurance)

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  • 18 other fields

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Control No.
Surplus Lines Statement (Form SL-8)
State of Connecticut
Insurance Department (Rev. 07/2013)
1. Name and Address of Surplus Lines Broker
2. Producing Agent (not agency)
2a. CT License No.
3. Agency Represented
3a. CT License No.
4. Name and Location on Risk
5a. Surplus Lines Insurer(s) and NAIC No.
5b. Surplus Lines Insurer(s) and NAIC No.
6. Kind of Insurance
6a. Limits
6b. Risk Description
7. Type of Policy
_________ New Business or
_________ Renewal
7b. Reason for Placement
8. Premium
8a.
_______ Term Premium
_______ Installment
_______ Subject to Audit
8b. Policy Period
9. Does the undersigned broker have on file evidence of declination by three licensed insurers and ineligibility for any residual market mechanism
per 38a-741 C.S.G? ____Yes ____No ____Exportable List
STATEMENT BY INSURED
I/We, the named insured, state that on ______________________________, 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. I/We have been advised that, in addition to commissions, I/We will be charged a service fee as set
out in 9a and 9b.
_____________________________________________________________
Signature of Insured
STATEMENT BY SURPLUS LINES BROKER
I, as a licensed Surplus Lines Broker, authorized to transact insurance with the surplus lines insurer(s) named on this Surplus
Lines Statement, depose and declare under the penalties provided for false statements that the diligent effort has been made to procure
said insurance coverage from licensed insurers which are authorized to transact the class of insurance involved and which accept in the
usual course of business, insurance on risks of the same class described herein. This insurance has been procured with the surplus lines
insurer(s) named on this Surplus Lines Statement, which insurance is only the excess over amounts procurable from licensed insurers.
__________________________________________________________
Signature of Surplus Lines Broker
Timothy Craig; 4728 Lisborn Drive, Carmel, IN 46033
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STATE OF CONNECTICUT
INSURANCE DEPARTMENT
INSTRUCTIONS FOR COMPLETING THE SURPLUS LINES STATEMENT (Form SL-8)
1. Refers to the licensed surplus lines broker and its’ Connecticut license number.
2. Refers to the producing agent and his/her Connecticut license number.
3. Refers to the producing agency and its’ Connecticut license number.
4. Indicate the name and location of the risk.
5. Identify the “White List” insurer/s through which the business is written. The White list
is available on our web site at www.ct.gov/cid. You will find surplus lines insurers
among the "List of Licensed Companies, Approved Reinsurers and Surplus Lines
Insurers (pdf 283 kb)". A "k" in the type column will indicate the company is a surplus
lines insurer. This list is compiled and maintained by the Financial Regulation
Division.
6. Enter the kind of insurance, limits (6a), and Risk Description (6b). “Risk Description”
should identify the type of operation or risk (i.e. manufacturer, complex, etc.)
7. Select new or renewal business. Indicate reason for placement (7b) (i.e. coastal
homeowner, vacant.)
8. Indicate the premium and the type of payment (8a). The policy period must show
specific effective and expiration dates (b). Indicating “one year” or “six months” is not
acceptable.
9. In response to question, select yes, no or exportable list. Indicate the amount of the
broker service fee assessed in box 9a. Indicate the amount of the producer service
fee assessed in box 9b.
Control number must be assigned by the surplus lines broker in numerical sequence,
beginning with no. 1, followed by a hyphen and the last two digits of the year of the
effective date of the policy. The statement must bear the signatures of the insured
and the broker. Failure to adhere to filing deadlines may result in administrative
action.
All statements are to be filed with the Quarterly Tax Returns on February 15
th
, May
15
th
, August 15
th
and November 15
th
.
www.ct.gov/cid
P.O. Box 816 Hartford, CT 06142-0816
An Equal Opportunity Employer
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Surplus Lines Statement (Form SL-8) (James Allen Insurance)

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Completed 11 August 2021

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