Surplus Lines Diligent Effort Affidavit Form - Dora, Colorado
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1Surplus Lines Diligent Effort Affidavit
This original executed form must be kept on file with the surplus lines broker & made available to the Division of
Insurance upon request. Surplus lines producers must report policies & premiums in their surplus lines logon
account: Inquiries: Dora_ColoradoInsuranceSurpluslinestax@state.co.us.
Please Print
10-5-103, C.R.S. Conditions for export
(1) If certain insurance coverages cannot be procured from admitted insurers, such coverages, designated in this
article as "surplus lines", may be procured from non-admitted insurers, subject to the following conditions:
(a) The insurance must be procured through a licensed broker.
The policy appearing on this affidavit has been produced and placed by the named Colorado Surplus Lines
Producer/Broker: _______________________________________ CO Surplus Lines License #____________________
Firm/Agency: __________________________________________ Ph #: ____________________ Date: _____________
(b) The full amount of insurance required shall not be procurable, after diligent effort has been made to do
so, from among admitted insurers authorized to transact and actually transacting that kind of insurance in
this state; and placing the insurance with a non-admitted insurer shall not be for the purpose of securing a
lower premium rate than that which would be accepted by an admitted insurer unless the premium rate
quoted by the admitted insurer is more than ten percent higher than that quoted by the non-admitted
insurer.
(c) At the time of the procuring of any such insurance, an affidavit setting forth facts referred to in paragraph
(b) of this subsection (1) must be executed by the broker.
Three admitted insurers that declined coverage and the reason:
1. _____________________________________________________________________________________
2. _____________________________________________________________________________________
3. _____________________________________________________________________________________
10-5-103.5, C.R.S. Producing broker's affidavit
Any broker exporting insurance under this article, at the request of any other licensed agent or broker, may
accept an affidavit executed by such other agent or broker, in such form as may be prescribed or accepted by the
commissioner, as evidence that such insurance was eligible for export under
section
10-5-103. Except as the
commissioner may otherwise provide, the broker shall file or cause to be filed such affidavit with the
commissioner within thirty days after the insurance was so procured, (this is referring to the affidavit in the
surplus lines producer’s logon account). This original executed form must be kept w/the surplus lines producer.
Circle Procurement Type: Direct or Referred from named CO PC Producer:__________________________________
License #________________ Firm/Agency______________________________Ph#_________________Date_________
The following coverage is placed in eligible, non-admitted insurer in compliance with the Surplus Lines Insurance
Act, subsection 10-5-108, Colorado Revised Statutes.
INSURED DATA
Name of Insured: ___________________________________________________________________________________
Street Address: ______________________________________________________________Ph #___________________
City: ____________________________________State: ____________________ Zip Code_______________________
Filing Type: __________________________________________________ (New, Renewal, Endorsement, Audit)
Policy Period (MM/DD/YY) __________________________to______________________________ (MM/DD/YY)
Type of Insurance: __________________________________ Policy #: _______________________________________
Surplus Lines Insurer Underwriting the Policy: ___________________________________________________________
1560 Broadway, Suite 850, Denver, CO 80202 P 303.894.7499 Toll Free 800.930.3745 F 303.894.7455
Revised 10/16/2015
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