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Follow the step by step instructions. Please use the interactive form or use a
Typewriter to fill the submission in.
Hand writing makes the forms extremely hard to read. Printer Friendly Version
PART ONE
Indicate if Risk is on most recent ARL ____ (yes or no). If yes
what is the category? ____ (If
risk is on the Approved Risk List (ARL), you do not have to
do the diligent search. The most
recent ARL can be found on the MSLAA website at www.mslaa.org/formsandmaterials.html and is updated
about every 6 months.)
1.
Please indicate Type of Risk (ex: Log Cabin, Explosive Factory,
Chiropractor, Daycare etc.)
1A. A Detailed explanation
why the risk is Not Available from an authorized insurer. The answer must be detailed or the
submission will be sent back to the Surplus Line Producer. Do not use these Reasons Not To Use explanations on the submission
form.
2.
Please indicate prior insurer (If there is no prior
insurer write “None” or “No Prior
Insurance” if it is the same write “same insurer”. Do not leave the field blank.
2A. Please indicate why the Prior
Insurer did not renew (if it is
the same insurer then write “same”).
2B. If a renewal was offered please
list the renewal quote (Premium Only).
3.
If you are filing using the 10% AND $1500 exception (MCA
33-2-302(1)(d)(i) and (2)) put YES or NO
(If you have any questions about
this statute please call the stamping office at 406-443-7324 and ask for
Nick or the Department of Insurance at 406-444-2040 and ask for Barb Vander
Mars).
3A. If you put NO, proceed to #4. If
you put YES then list the
financial stability rating system that was used to determine if the
non-admitted company was equivalent to an “A” rating or higher. (Example:
AM Best) Also put the rating that was listed and the effective date of
the rating. (DO NOT SEND IN
PROOF OF RATING; ONLY KEEP A COPY FOR YOUR RECORDS.)
4.
Please indicate the name of the 3 companies that you
completed the diligent search with
4A. Only put the dollar amounts if you
are using the 10% AND $1500 exception from question #3.
5.
Please indicate Name of Producer that placed the
business with the customer.
6.
Please indicate name of Agency and Address.
7.
Please have Producer Signs and Dates part one.
8.
Please indicate Producers Montana License Number.
9.
Please have Notary Sign and Stamp Part One.
PART TWO
1.
Please indicate Name of Surplus Lines Producer that
placed the business with the company.
2.
Please indicate name of Agency and Address.
3.
Please have Surplus Lines Producer Sign and Dates part two.
4.
Please indicate Surplus Lines Producers License
Number.
5.
Please have Notary Sign and Stamp part two.
PART THREE
1.
Please indicate Name of Unauthorized Insurance
Company (If it is Lloyds then list the syndicate numbers)
(Note: A list of eligible
companies is available at http://www.mslaa.org/formsandmaterials.html make
sure you check the list before you write business with the insurance
company. If the company is not on
the list, you will not be able to legally write the risk in the state of
Montana).
2.
Please indicate Policy Effective and Expiration Dates.
3.
Please indicate Limits of Coverage.
4.
Please indicate Premiums, Inspection Fees and
Taxes. (Note: Directions for
calculating Taxes can be found on the MSLAA website at www.mslaa.org/formsandmaterials.html. The Microsoft Word document is
interactive and calculates the taxes and fees automatically).
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