Diligent Search Report Form – Fill Out and Use This PDF

DILIGENT SEARCH REPORT

(Please Refer to the Instructions on Page 3 of This Form)

1.____________________________________________ hereby submits that he/she is:

(Full Name of the Individual)

(A) Duly licensed under California Department of Insurance license number _________________;

OR (B) Duly licensed and authorized to act as an endorsee on the organizational license of

________________________________________, California Department of Insurance license number ______________;

(Name of Organization)

and (C) that he/she or said organizational licensee was engaged by the insured named herein, or the insured's broker, to obtain insurance as described in this report;

and (D) is the licensee who performed or supervised this diligent search.

2.(A ) Name of Insured __________________________________________________________________________

(B) Address of Insured _____________________________________________________________________

(Street and Number)

_______________________________________________________________________

(City)(State) (Zip Code)

(C ) Description of Risk _______________________________________________________________________

(e.g. Laundromat, liquor store, …NOT TYPE OF COVERAGE)

(D) Location of Risk _________________________________________________________________________

(Street and Number)

_________________________________________________________________________________

(City)(State) (Zip Code)

(E) Type of Insurance coverage ___________________________________

(Enter Appropriate Code Number from Pg. 3)

3.If Private Passenger Automobile Liability Insurance is identified on line 2(E), complete the following:

(A)Does the insured qualify as a "Good Driver" under Section 1861.025 of the California Insurance Code?

(CHECK ONE) YES

NO

(B)Does the coverage that you have placed include, in whole or in part, the limits of coverage provided under

the California Automobile Assigned Risk Plan (CAARP)? (CHECK ONE) YES

NO

(C)If YES, has this risk been submitted to and found to be ineligible by CAARP?

(CHECK ONE) YES

NO

If your answer is NO, then this coverage cannot be placed with a non-admitted insurer. (See Insurance Code section 1763.5)

4.If Health Insurance is identified on line 2(E), does the insured qualify as a "Small Employer" under Section

10700(x) of the California Insurance Code? (CHECK ONE)	YES	NO

5.If this insurance was placed pursuant to Section 125 et seq. of the California Insurance Code governing transactions with risk purchasing groups authorized by the Federal Liability Risk Retention Act of 1986, complete the following:

(A) Provide the name and address of the purchasing group of which the insured is a member____________________

__________________________________________________________________________________________

6.(A) Describe the diligent efforts made to place this coverage with admitted insurers and describe how the search was performed (please add additional pages if necessary):

_____________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

(SL-2 (Revised 06/2004)

(B)If search was performed by someone other than the person named on line 1, please provide full name of that individual:

___________________________________________________

7.(A) Was the risk described in Section 2 submitted by you or by someone under your supervision to at least (3) insurers that are admitted in California and who actually write the type of insurance described on lines 2(C) and

2(E)? (CHECK ONE) YES

NO

(B) If YES, please complete ALL sections of the following table; if NO, skip to Section 8:

Full Name of Admitted Company

First & Last Name of Company

Check if

Month,

Year

Declination

Representative AND Telephone

Employee (E)

of Declination

Code*

Number

or Agent (A)

1.

______________________________

E ( )

(

)

-

A ( )

/

or “Online Declination”

Website________________________

2.

E ( )

______________________________

(

)

-

A ( )

/

or “Online Declination”

Website________________________

3.

_______________________________

E ( )

(

)

-

A ( )

/

or “Online Declination”

Website________________________

*Declination Codes: 1 - Company's capacity reached

2-underwriting reason

3-refused to state

4-other

8.If 7(A) was answered NO, complete the following:

(A) Did you determine that fewer than 3 admitted insurers actually write the type of insurance described on lines

2(C) and 2(E)? (CHECK ONE) YES

NO

(B)If NO, please explain in detail why the risk was submitted to less than three admitted insurers in California that write this type of insurance.

_______________________________________________________________________________________

___________________________________________________________________________________________

________________________________________________________________________________________

(C) If YES, please describe how you made this determination.________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

The undersigned licensee hereby certifies that this report is true and correct, and that this risk is not being placed with a non- admitted insurer for the sole purpose of securing a rate or premium lower than the lowest rate or premium available from an admitted insurer.

___________________________________________________________________	__________________
(Signature of Licensee Named on Line 1)	(Date)
SL-2 (Revised 06/2004)