Fillable Montana Surplus Lines Submission Form printable pdf download

MONTANA SURPLUS LINES SUBMISSION FORM

NOTICE: Complete entire submission form. Do not leave any blanks. Write “NA” if any question is “not applicable.” Incomplete submission forms will be returned.

INSURED:

POLICY NUMBER:

MT LOCATION ONLY

MT ADDRESS:

MT LOCATION ONLY

IS THIS FILED ON A BINDER?

PART 1: AFFIDAVIT OF PRODUCING INSURANCE PRODUCER SECTION

YES

State of

)

:ss.

County of

)

The undersigned hereby certifies upon oath that the insurance which is the subject of this affidavit is in accordance with Title 33, § 33-2-301, et seq. MCA, the Montana Surplus Lines

Insurance Law. The insurance which is the subject of this affidavit was not procured for 1) the purpose of securing advantages as to the terms of the insurance contract and 2) the purpose

of obtaining a lower premium rate than would be accepted by the authorized insurer except as provided in § 33-2-302 (1) (d) (i) and (2), MCA. Furthermore: 1) The insurance which is the

subject of this affidavit is a line of insurance which appears on the most recent Approved Risk List (ARL) issued by the Commissioner of Insurance; or 2) Immediately before requesting

from an unauthorized insurer the insurance which is the subject of this affidavit, I endeavored diligently and unsuccessfully to secure equivalent coverage from authorized insurers holding

certificates of authority to transact this line or the full amount of the line of insurance in the State of Montana; and 3) I have expressly advised the insured prior to placing the insurance that

the surplus lines insurer with whom the insurance is placed is not authorized in this state and is not subject to the same supervision as an authorized insurer; and in the event of the

insolvency of the surplus lines insurer, the property and casualty guaranty fund of the state will not pay losses under the surplus lines coverage.

Is the risk included on the most recent Approved Risk List?

YES or

NO If so, in which category? (Ex: GL-01)

If not included on the most recent ARL describe 1) Type of Risk

1a) EXPLAIN in detail why insurance for this risk is unavailable from an authorized insurer: (COMPLETE SENTENCE)

2) Indicate prior insurer:

2a) Explain why the prior insurer, if an authorized insurer, did not renew:

2b) If a renewal was offered, what was the renewal quote?

(IF NONE PUT “NONE”)

Are you filing using the 10%

AND $1500 exception? (33-2-302(1)(d)(i) and (2) MCA) (Y or N )

____

(DILIGENT EFFORT IS REQUIRED)

If YES, the financial stability rating system used was

FOR OFFICE USE ONLY

and the rating was

as of

(effective date).

VERIFIED RATING:

(If YES, you are affirming: 1. I have provided the insured with the disclosure information on the form approved by the Commissioner. 2. The unauthorized market quote was placed with

a surplus lines company that is “A” rated or better. 3. The authorized market quote(s) that was used was the lowest premium from the diligent effort. 4. The difference between the

authorized market quote(s) and the unauthorized market quote(s) meets both the 10% AND the $1500 requirements. 5. I listed the lowest quotes obtained from the authorized market

search in #4 below.)

4) List a minimum of three authorized insurers you contacted for your diligent efforts to place this insurance:

I, _____________________________________, being of lawful age and being first duly sworn, on oath, depose and say that I am one and the same

person whose name is subscribed to this affidavit; that I have read the same and know the contents thereof; and that the statement of facts contained

herein are true.

X_____________________________________________________

________________#

Montana Producer/Agency License No.

Original Signature of Producing Insurance Producer is Required

Date

Agency Name

Address

Subscribed and sworn to before me this

, 20

Signature

Printed Name of Notary

Stamp or Seal

Notary Public for the State of

Residing at

My Commission expires

PART 2: Montana Surplus Lines Insurance Producer Section

I,____________________________________(printed name of surplus lines producer), affirm that: 1) I am the producer that placed this risk

with the unauthorized insurer; 2) this line of insurance appears on the most recent Approved Risk List (ARL) issued by the Commissioner of Insurance

or that I have, to the best of my ability, attempted to place this line of insurance through an authorized insurer and am unaware of any authorized

insurer transacting this line or the full amount of this line of insurance in Montana; and 3) I have complied with § 33-2-302, MCA.

Agency Name

Address as it appears on the MT Surplus Lines License

Original Signature of Surplus Lines Producer is Required

Date

Montana Surplus Lines License No.

PART 3: Premium / Tax / Fee Information Section

Name of Unauthorized Insurer(s):

Lloyds Syndicate #

Policy Period From:

To:

Limits of Coverage:

If this policy is a multi-year policy with the policy term greater than 12 months, this form is to be completed

only in the initial year of the policy. For all subsequent years, report policy premium on the Montana

FOR OFFICE USE ONLY:

Surplus Lines Multi-Year Policy Premium Form

ACCEPTED STAMP ONLY

Policy Premium:

Fire Premium:

0.00

Premium Tax: (2 ¾%)

Fire Tax (2.5%):

Stamping Fee: (1%)

0.00

Inspection Fee:

NOTICE: Under Montana law, inspection fees for the actual cost of inspecting the risk to be covered may be charged. Other fees, such as

placement fees or policy fees, are not permitted.

SEND: THE ORIGINAL SUBMISSION, A COPY OF THE ORIGINAL SUBMISSION FORM AND A SELF-ADDRESSED STAMPED ENVELOPE WITH SUFFICIENT POSTAGE TO

RETURN THE STAMPED COPY OF THE SUBMISSION FORM AND ANY OTHER DUPLICATES YOU WOULD LIKE RETURNED (I.E.; DECLARATION PAGES AND/OR BINDERS). IF

COPIES ARE NOT PROVIDED, NONE WILL BE RETURNED. TO: MONTANA COMMISSIONER OF SECURITIES AND INSURANCE, SURPLUS LINES, 840 HELENA AVENUE,

HELENA, MT 59601.

Montana Surplus Lines Submission Form

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