Notice Of Excess Line Placement printable pdf download

Notice Of Excess Line Placement

NOTICE OF EXCESS LINE PLACEMENT

Date:

Consistent

with

the

requirements

the

New

York

Insurance

Law

and

Regulation

__________________________ is hereby advised that all or a portion of the required coverages have been

placed by __________________________________ with insurers not authorized to do an insurance business in

New York and which are not subject to supervision by this State. Placements with unauthorized insurers can

only be made under one of the following circumstances:

a) A diligent effort was first made to place the required insurance with companies authorized in New

York to write coverages of the kind requested; or

b) NO diligent effort was required because i) the coverage qualifies as an “Export List” risk, or ii) the

insured qualifies as an “Exempt Commercial Purchaser.”

Policies issued by such unauthorized insurers may not be subject to all of the regulations of the

Superintendent of Financial Services pertaining to policy forms. In the event of insolvency of the

unauthorized insurers, losses will not be covered by any New York State security fund.

TOTAL COST FORM (NON TAX ALLOCATED PREMIUM TRANSACTION)

In consideration of your placing my insurance as described in the policy referenced below, I agree to pay the

(1)

total cost below which includes all premiums, inspection charges

and a service fee that includes taxes,

(1)

stamping fees, and (if indicated) a fee

for compensation in addition to commissions received, and other

(1)

expenses

(1)

I further understand and agree that all fees, inspection charges and other expenses denoted by

are fully

earned from the inception date of the policy and are non-refundable regardless of whether said policy is

cancelled. Any policy changes which generate additional premium are subject to additional tax and stamping

fee charges.

Re: Policy No.

Insurer

Policy Premium

Insurer Imposed Charges:

(1)

Policy Fees

(1)

Inspection Fees

$__________________

Total Taxable Charges

Service Fee Charges:

Excess Line Tax (3.60%)

Stamping Fee

(1)

Broker Fee

(1)

Inspection Fee

(1)

Other Expenses (specify)

_____________________________

$ ___________________

Total Policy Cost $ ___________________

_____________________________________

(Signature of Insured)

(1)

= Fully earned

NYSID Form: NELP/2011

Notice Of Excess Line Placement

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