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Example - Delaware Sl Form

THIS FORM MUST SIGNED BY THE LICENSED PRODUCING AGENT AND FORWARDED TO THE LICENSED SURPLUS LINES BROKER OR SIGNED AND RETAINED BY THE SL BROKER

RETAIN AS PART OF SURPLUS LINES BROKER RECORDS

THIS FORM MUST BE OPEN TO EXAMINATION BY THE COMMISSIONER AT ALL TIMES FOR 5 YEARS AFTER ISSUANCE OF THE COVERAGE TO WHICH IT RELATES. (18 DEL. C., §1915)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Submitted by: (select one)

 

 

 

 

DELAWARE INSURANCE DEPARTMENT

 

 

 

 

PRODUCER

 

 

 

 

 

 

 

SURPLUS LINES

 

 

 

 

SL BROKER

 

 

 

 

 

 

STATEMENT OF DILIGENT EFFORT

 

 

 

Form SL-1904

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

v.06-2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DO NOT SUBMIT THIS FORM TO THE INSURANCE DEPARTMENT

 

POLICY NUMBER

 

SURPLUS LINES INSURER NAME

 

 

 

 

NAIC #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSURED'S NAME AND MAILING ADDRESS:

 

 

POLICY TERM INFORMATION

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

Effective Date

 

 

 

 

Expiration Date

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM/DD/YYYY Format

MM/DD/YYYY Format

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AMOUNT OF INSURANCE

Property

$

 

 

Casualty

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION OF RISK

 

 

 

 

 

DESCRIPTION OF COVERAGE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I declare under the penalties provided by law that I have made a diligent effort to procure the insurance coverage described above 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 as the risk described above. Having been unable to secure such coverage, I have resorted to coverage with companies not licensed to operate in the State of Delaware and which are not under the jurisdiction of the Insurance Department of the State of Delaware.

Furthermore, this insurance was not exported for the purpose of securing lower rates than would be accepted by an authorized insurer or because of the terms of the contract.

Among the licensed insurers declining to insure this risk or declining to increase the amount of insurance on this risk, are the following:

1.Name & NAIC # of Insurer: Name & Telephone # of Contact:

Reason for Declining:

2.Name & NAIC # of Insurer: Name & Telephone # of Contact: Reason for Declining:

3.Name & NAIC # of Insurer: Name & Telephone # of Contact: Reason for Declining:

I further attest that I have explained to the insured that the insurance described herein is being placed with an insurance company not authorized to do business in Delaware. The insured understands that the insurance company is not a member of the Delaware Insurance Guaranty Association and that Chapter 42 of the Delaware Insurance Code is not applicable to claimants or insureds of said company. As required in 18 Del. C., §1909, I have delivered to the insured evidence of the insurance upon which has been stamped:

“This insurance contract is issued pursuant to the Delaware Insurance Laws by an insurer neither licensed by nor under the jurisdiction of the Delaware Insurance Department.”

I declare that I have the insurance coverage here described was procured pursuant to Chapter 19 of Title 18, the Delaware Insurance Code, and that the information contained in this submission is true.

Name of Producer/ SL

 

 

DE Lic # of

Agency

 

 

Agency

 

 

(Type or print name of Agency)

Name of Producer/ SL

 

 

DE Lic #

Broker

 

 

Individual

 

 

(Type or print name of Individual)

Producer/ SL Broker

 

 

 

Signature

Sign Here

 

Date:

Blank SL-1904-06

Direct any questions to: Ann.Fletcher@state.de.us

Delaware Sl: Usage Guide

Completing the Delaware SL form is a straightforward process. This form is essential for documenting efforts made to secure surplus lines insurance. After filling it out, it must be signed by the licensed producing agent and sent to the licensed surplus lines broker. Alternatively, the broker can sign and retain it as part of their records. It’s important to keep this document accessible for examination by the commissioner for five years after the coverage is issued.

  1. Begin by selecting the appropriate option under "Submitted by." Choose either "Delaware Insurance Department," "Producer," or "Surplus Lines SL Broker."
  2. Fill in the "Policy Number" field with the relevant policy number.
  3. Provide the "Surplus Lines Insurer Name" and the corresponding "NAIC #" (National Association of Insurance Commissioners number).
  4. In the "Insured's Name and Mailing Address" section, enter the name and address of the insured individual or entity.
  5. Complete the "Policy Term Information" section by entering the name, effective date, and expiration date in the specified MM/DD/YYYY format.
  6. Indicate the "Amount of Insurance" for both Property and Casualty, entering the respective dollar amounts.
  7. In the "Location of Risk" section, provide the address where the risk is located.
  8. Describe the coverage in the "Description of Coverage" section, ensuring clarity and accuracy.
  9. List at least three licensed insurers that declined to insure the risk. For each, provide the name, NAIC #, contact name, telephone number, and the reason for declining.
  10. Confirm that you have explained to the insured that the coverage is with an unauthorized insurance company and that they understand the implications.
  11. Deliver the evidence of insurance to the insured, ensuring it is stamped with the required statement regarding the unauthorized insurer.
  12. Sign the form in the designated area, including the name of the producer or SL broker and their Delaware license number.
  13. Finally, date the form before submission.

Documents used along the form

The Delaware SL form is an essential document for securing surplus lines insurance in Delaware. However, it is often accompanied by several other forms and documents that help clarify the process and ensure compliance with state regulations. Below is a list of these accompanying documents, each serving a specific purpose in the surplus lines insurance process.

  • Statement of Diligent Effort (Form SL-1904): This form is crucial for demonstrating that the licensed producer has made a genuine attempt to obtain coverage from authorized insurers before resorting to surplus lines. It outlines the efforts made and the reasons for any declines from licensed insurers.
  • Insurance Policy Document: This is the actual policy that outlines the coverage provided by the surplus lines insurer. It includes details such as the policy number, coverage limits, and terms and conditions.
  • ATV Bill of Sale Form: To facilitate your vehicle transaction, refer to the comprehensive ATV Bill of Sale form guide for accurate documentation and compliance.
  • Insurer's Financial Statement: This document provides insight into the financial health of the surplus lines insurer. It helps the producer and insured assess the insurer's ability to fulfill claims.
  • Certificate of Coverage: This certificate serves as proof that the insurance policy is in effect. It is often requested by third parties, such as lenders or landlords, to verify coverage.
  • Disclosure Statement: This document informs the insured about the nature of the surplus lines insurance, including the fact that the insurer is not licensed in Delaware and does not participate in the Delaware Insurance Guaranty Association.
  • Producer's License Verification: This document confirms that the producer is licensed to sell surplus lines insurance in Delaware. It is often required to ensure that all parties are operating within the legal framework.
  • Application for Surplus Lines Coverage: This application collects essential information about the risk being insured and the insured party. It helps the surplus lines broker assess the risk and determine appropriate coverage.
  • Endorsements and Amendments: These documents modify the original policy to add or change coverage terms. They are essential for tailoring the insurance policy to meet specific needs of the insured.

Understanding these documents is vital for anyone involved in the surplus lines insurance process in Delaware. Each plays a role in ensuring that the insurance is obtained legally and effectively, protecting both the insured and the producer.

Key takeaways

Here are key takeaways regarding the Delaware SL form:

  1. The form must be signed by the licensed producing agent.
  2. It should be forwarded to the licensed surplus lines broker.
  3. Alternatively, the surplus lines broker can sign and retain the form.
  4. Records must be kept for five years and be open to examination by the Commissioner.
  5. Do not submit this form to the Delaware Insurance Department.
  6. The form requires specific details, including policy number and insurer information.
  7. It is essential to document diligent efforts made to procure insurance from licensed insurers.
  8. The insured must be informed that the coverage is with an unauthorized insurer.
  9. Insured parties should understand that they are not covered by the Delaware Insurance Guaranty Association.
  10. Ensure the form is filled out accurately, as it attests to compliance with Delaware insurance laws.

Completing the Delaware SL form accurately is crucial for compliance and to ensure all parties understand their rights and obligations.

Find More PDFs

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Delaware Quarterly Taxes - This form reinforces the responsibility of fiduciaries in handling trust or estate tax matters.

File Details

Fact Name Fact Description
Governing Law The Delaware SL form is governed by 18 Delaware Code, §1915.
Purpose This form is used to document diligent efforts made by agents to secure insurance coverage from licensed insurers.
Retention Requirement The form must be retained by the surplus lines broker for five years after the issuance of the related coverage.
Signature Requirement The form must be signed by the licensed producing agent and forwarded to the licensed surplus lines broker.
Examination by Commissioner The form must be open to examination by the Commissioner at all times during the retention period.
Submission Instructions This form should not be submitted to the Delaware Insurance Department.
Insurer Information Details about the surplus lines insurer, including name and NAIC number, must be provided on the form.
Explanation Requirement The insured must be informed that the insurance is placed with a non-licensed insurer in Delaware.
Guaranty Association The insured must understand that the non-licensed insurer is not a member of the Delaware Insurance Guaranty Association.
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