Form Dwl - Defence-Within-Limits-Filing Compliance Questionnaire - New York State Department Of Financial Services
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1
2NEW YORK STATE DEPARTMENT OF FINANCIAL SERVICES
DEFENSE-WITHIN-LIMITS FORM FILING COMPLIANCE QUESTIONNAIRE
PAGE 1 of
COMPANY
Co. File No.
Company Contact:
Phone Number:
E-Mail Address:
TYPE OF INSURANCE
(for Pollution Insurance for Owners/Operators of Underground Storage Tanks, complete page 2)
AMOUNT OF OFFSET
100%
Offset Against
Limits only
50%
Deductible Only
Other
%
Both
(Specify)
Instructions: All applicable items must be answered. Responses in the shaded area indicate non-
compliance with Regulation No. 107. Form, page and paragraph references that bring the submission into
compliance must be included. Failure to complete all items, or responses in the shaded area, will result in
this filing being returned without further review.
I.
ALL POLICIES
complies with [§71.3(d)]
YES
NO
A. Minimum Limit of $
B. Face of policy contains a conspicuous notice that the policy is
YES
NO
written on a “defense-within-limits” basis [§71.5(a)]
C. Face of application contains a conspicuous notice that the
policy is written on a “defense-within-limits basis” [§71.5(a)]
YES
NO
D. 1.
Policy contains insured’s acknowledgement (check all that
apply) [§71.5(b)(1) – (3)]
YES
NO
the limits can be reduced by defense expenses
the limits can be exhausted by defense expenses
YES
NO
the deductible can be reduced or exhausted by
defense expenses
YES
NO
or
D. 2
The notice on the face of the policy and application
contains the information required by §71.5(d)
YES
NO
E.
Unless this policy provides coverage for owners or operators
of underground storage units, does the policy contain a
YES
separate defense limit?
NO
II.
POLICIES CONTAINING 100% OFFSETS
Policy provides that insured can:
1. Select defense attorney or consent to insurer’s
choice [§71.3(c)(1)]
YES
NO
2. Participate in the defense [§71.3(c)(2)]
YES
NO
3. Consent to the settlement, such consent not to be
unreasonably withheld [§71.3(c)(3)]
YES
NO
III.
POLICIES CONTAINING LEGAL SERVICES INSURANCE
No more than 25% of the policy’s per claim or aggregate limit can
be reduced by payment of legal services insurance [§71.3(f)]
YES
NO
NOTE: All sections cited are to the applicable sections of Regulation No. 107
Form Number: DWL (Ed. 3/2003)
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