In an evolving insurance landscape, the Due Diligence Form (Form DDF – Revised 8/09), issued by the Offices of the West Virginia Insurance Commissioner, emerges as a pivotal document, especially within the surplus lines market. This comprehensive form serves multiple purposes, notably for new applications, renewals, or rewrites, accompanied by a mandatory Customer ID number. Its rigorous requirements demand detailed information about the risk to be insured, including but not limited to, the insured's name and address, risk description, and the specific type of insurance coverage sought. A critical component of the form is the inquiry into whether the requested insurance type and location are listed on the West Virginia Export List. If not, it mandates, under the threat of perjury, a diligent search by the licensed individual insurance producer for comparable coverage from licensed insurers within the state. It uniquely captures the outcomes of these searches, including the names of insurers that declined the risk, their reasons for declination, and pertinent contact information. Importantly, the form includes a notice to the insured about the implications of proceeding with a surplus lines insurer, highlighting matters of solvency and the absence of protection by any West Virginia guaranty fund. Culminating in affirmations by both the insured and the licensed insurance producer, the Due Diligence Form ensures a transparent, thorough vetting process, necessitating retention in the producer's office for potential examination by the commissioner, a requirement underscored by regulations W.Va. C.S. R. §114-20-4.2(a) and §114-20-4.5.
| Question | Answer |
|---|---|
| Form Name | Due Diligence Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | west virginia due diligence form, west virginia department of insurance surplus lines due diligence form, wv due diligence form, blank due diligence form |
Offices of the West Virginia Insurance Commissioner
Due Diligence Form (Form DDF – Revised 8/09)
New
Renewal
Rewrite
Customer ID #
This form must be forwarded to the licensed surplus lines licensee placing the risk in the surplus lines market and must be retained in his or her office and may be examined at any time by the commissioner pursuant to W.Va. C.S. R.
1.
hereby submits that he/she is a duly licensed individual insurance producer under West
Producer Name (Type or Print)
Virginia Offices of the Insurance Commissioner license number
2.Risk Description
(A)Insured Name
Type or Print
(B)Address of Insured
Street and Number, City, State, Zip
(C)Description of Risk
e.g. Laundromat, Liquor Store. (Do Not List Type of Coverage)
(D)Location of Risk
Street and Number, City, State, Zip
(E)Type of Coverage
3.Is the type of coverage described on lines 2(C) and 2(E) on the current West Virginia
Export List for both the type of insurance and the location in the State? |
YES |
NO
If you answered NO, continue to Number 4 below.
4.I declare under penalty of perjury, that I have made a diligent search to procure the insurance coverage described above for licensed insurers in West Virginia which are authorized to transact the kind of insurance involved and which provide, in the course of business, coverage comparable to the coverage being sought. I have contacted the insurers that I represent customarily writing the find of insurance requested by the insured and have been unable to procure said insurance. The licensed insurers declining to insure this risk are as follows:
Full Name of Admitted Company
NAIC # Name of Company Representative and Telephone Number
Date of
Declination
Declination
Code*
*Declination Codes: 1=Company’s Capacity Reached; 2=Underwriting Reason; 3=Refused to State; 4=Other
If Other was used as a Declination Code, explain below:
NOTICE TO INSURED
I,
, have been expressly advised prior to the placement of the insurance that:
Insured (Print or Type)
1)The surplus lines insurer with which the insurance is placed is not an admitted authorized insurer in this State and is not subject to the Insurance Commissioner’s supervision; and
2)In the event the surplus lines insurer becomes insolvent, claims will not be paid nor will unearned premiums be returned by any West Virginia guaranty fund.
Signature of Insured
Date
The undersigned licensed individual insurance producer who performed or supervised the diligent search hereby certifies that this report is true and correct, and that this risk is not being placed with a
Licensed Individual Insurance Producer (Print or Type) |
Signature of Licensed Individual Insurance Producer |
Date |