Diligent Search Report - Landy Insurance

ADVERTISEMENT

DILIGENT SEARCH REPORT
(Please Refer to the Instructions on Page 3 of This Form)
1.
hereby submits that he/she is:
(Full Name of the Individual)
(A) Duly licensed under California Department of Insurance license number
;
OR
(B) Duly licensed and authorized to act as an endorsee on the organizational license of
,
California Department of Insurance license number
;
(Name of Organization)
and (C) that he/she or said organizational licensee was engaged by the insured named herein, or the insured's broker,
to obtain insurance as described in this report;
and (D) is the licensee who performed or supervised this diligent search.
2.
(A)
Name of Insured
(B)
Address of Insured
(Street and Number)
(City)
(State)
(Zip Code)
(C)
Description of Risk
(e.g. Laundromat, liquor store, ...
NOT TYPE OF COVERAGE)
(D)
Location of Risk
(Street and Number)
(City)
(State)
(Zip Code)
(E)
Type of Insurance coverage
550
(Enter Appropriate Code Number from Pg. 3)
3.
If
Private Passenger Automobile Liability Insurance
is identified on line 2(E), complete the following:
(A)
Does the insured qualify as a "Good Driver" under section 1861.025 of the California Insurance Code?
(CHECK ONE)
YES
NO
(B)
Does the coverage that you have placed include, in whole or in part, the limits of coverage provided under
the California Automobile Assigned Risk Plan (CAARP)?
(CHECK ONE) YES
NO
(C)
If YES has this risk been submitted to and found to be ineligible by (CAARP)?
(CHECK ONE)
YES
NO
If your answer is NO, then this coverage cannot be placed with a non-admitted insurer. (See Insurance Code section 1763.5)
4.
If
Health Insurance
is identified on line 2(E), does the insured qualify as a "Small Employer" under Section
10700(x) of the California Insurance Code?
(CHECK ONE)
YES
NO
5.
If this insurance was placed pursuant to Section 125
et seq.
of the California Insurance Code governing
transactions with
risk purchasing groups
authorized by the Federal Liability Risk Retention Act of 1986,
complete the followinig:
(A) Provide the name and address of the purchasing group of which the insured is a member
Realtors Insurance Purchasing Group Association
75 Second Ave Suite 410 Needham, MA 02494
6.
(A)
Describe the diligent efforts made to place this coverage with admitted insurers and describe how the
search was performed (please add additional pages if neccessary):
(SL-2(Revised 06/2004)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 2