Delaware Form Sl 1904 PDF Details

The Delaware SL form, essential in the surplus lines insurance market, serves as a crucial documentation process for brokers and agents operating within Delaware. It underscores a commitment to diligence and regulatory compliance when securing insurance coverage from non-licensed insurers, a practice only permissible under specific conditions. This form, detailed with sections for policy information, insured’s details, and coverage descriptions, mandates the signature of a licensed producing agent or a surplus lines broker, affirming the exhaustive efforts made to procure insurance from licensed entities before resorting to the surplus lines market. Importantly, the form serves as a testament that the insured has been thoroughly informed that their coverage is placed with an insurer outside the traditional state insurance framework, recognizing such insurers do not fall under the Delaware Insurance Guaranty Association's protection. With a stringent requirement for this form to be readily accessible for examination by the Commissioner for five years post-issuance, it embodies a structured approach to ensure transparency, accountability, and protection for all parties involved in the transaction. Through this form, the Delaware Insurance Department emphasizes the need for meticulous record-keeping and the declaration of genuine efforts to place risks adequately within the licensed insurance market before exploring surplus lines, ensuring that such steps are taken not for rate advantages but a genuine lack of available coverage within conventional markets.

QuestionAnswer
Form NameDelaware Form Sl 1904
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names1904, SL-1904, insurers, SL

Form Preview Example

THIS FORM MUST SIGNED BY THE LICENSED PRODUCING AGENT AND FORWARDED TO THE LICENSED SURPLUS LINES BROKER OR SIGNED AND RETAINED BY THE SL BROKER

RETAIN AS PART OF SURPLUS LINES BROKER RECORDS

THIS FORM MUST BE OPEN TO EXAMINATION BY THE COMMISSIONER AT ALL TIMES FOR 5 YEARS AFTER ISSUANCE OF THE COVERAGE TO WHICH IT RELATES. (18 DEL. C., §1915)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Submitted by: (select one)

 

 

 

 

DELAWARE INSURANCE DEPARTMENT

 

 

 

 

PRODUCER

 

 

 

 

 

 

 

SURPLUS LINES

 

 

 

 

SL BROKER

 

 

 

 

 

 

STATEMENT OF DILIGENT EFFORT

 

 

 

Form SL-1904

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

v.06-2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DO NOT SUBMIT THIS FORM TO THE INSURANCE DEPARTMENT

 

POLICY NUMBER

 

SURPLUS LINES INSURER NAME

 

 

 

 

NAIC #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSURED'S NAME AND MAILING ADDRESS:

 

 

POLICY TERM INFORMATION

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

Effective Date

 

 

 

 

Expiration Date

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM/DD/YYYY Format

MM/DD/YYYY Format

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AMOUNT OF INSURANCE

Property

$

 

 

Casualty

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION OF RISK

 

 

 

 

 

DESCRIPTION OF COVERAGE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I declare under the penalties provided by law that I have made a diligent effort to procure the insurance coverage described above from licensed insurers which are authorized to transact the class of insurance involved and which accept, in the usual course of business, insurance on risks of the same class as the risk described above. Having been unable to secure such coverage, I have resorted to coverage with companies not licensed to operate in the State of Delaware and which are not under the jurisdiction of the Insurance Department of the State of Delaware.

Furthermore, this insurance was not exported for the purpose of securing lower rates than would be accepted by an authorized insurer or because of the terms of the contract.

Among the licensed insurers declining to insure this risk or declining to increase the amount of insurance on this risk, are the following:

1.Name & NAIC # of Insurer: Name & Telephone # of Contact:

Reason for Declining:

2.Name & NAIC # of Insurer: Name & Telephone # of Contact: Reason for Declining:

3.Name & NAIC # of Insurer: Name & Telephone # of Contact: Reason for Declining:

I further attest that I have explained to the insured that the insurance described herein is being placed with an insurance company not authorized to do business in Delaware. The insured understands that the insurance company is not a member of the Delaware Insurance Guaranty Association and that Chapter 42 of the Delaware Insurance Code is not applicable to claimants or insureds of said company. As required in 18 Del. C., §1909, I have delivered to the insured evidence of the insurance upon which has been stamped:

This insurance contract is issued pursuant to the Delaware Insurance Laws by an insurer neither licensed by nor under the jurisdiction of the Delaware Insurance Department.”

I declare that I have the insurance coverage here described was procured pursuant to Chapter 19 of Title 18, the Delaware Insurance Code, and that the information contained in this submission is true.

Name of Producer/ SL

 

 

DE Lic # of

Agency

 

 

Agency

 

 

(Type or print name of Agency)

Name of Producer/ SL

 

 

DE Lic #

Broker

 

 

Individual

 

 

(Type or print name of Individual)

Producer/ SL Broker

 

 

 

Signature

Sign Here

 

Date:

Blank SL-1904-06

Direct any questions to: Ann.Fletcher@state.de.us