Statement Of Diligent Effort printable pdf download

Statement Of Diligent Effort

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Florida Surplus Lines Service Office

STATEMENT OF DILIGENT EFFORT

Producing Agent__________________________________________ License Number _____________________

Name of Agency_____________________________________________________________________________

Has sought to obtain:

Type of Coverage __________________________________________________________________________ for

Named Insured _____________________________________________________from the following authorized insurers

currently writing this type of coverage:

(1) Authorized Insurer _________________________________ Person Contacted _____________________________

Telephone Number_____________________ Date of Contact _____________________________________________

The reason(s) for declination by the insurer was (were) as follows:

________________________________________________________________________________________________

(2) Authorized Insurer __________________________________ Person Contacted ____________________________

Telephone Number_______________________ Date of Contact __________________________________________

The reason(s) for declination by the insurer was (were) as follows:

_______________________________________________________________________________

(3) Authorized Insurer ________________________________ Person Contacted _____________________________

Telephone Number ________________________

Date of Contact _________________________________

The reason(s) for declination by the insurer was (were) as follows:

_______________________________________________________________________________

Signature of Producing Agent

Printed or Typed Name of Producing Agent

Document Verified by Surplus Lines Agent: Yes ___ No ____ Date Verified: _________________

DI4-1153

7/00

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Revision - Revised 09/06

Statement Of Diligent Effort