Diligent Search Report Form
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1
2DILIGENT 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 ___________________________________
(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
following:
(A) Provide the name and address of the purchasing group of which the insured is a member____________________
__________________________________________________________________________________________
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 necessary):
_____________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
(
SL-2 (Revised 06/2004)
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