NYSID Form 41C-W PDF Details

The NYSID 41C W form serves a critical function in the realm of insurance brokerage in New York, encapsulating essential procedures and disclosures mandated by state insurance regulations. This document is chiefly utilized by producing brokers who are tasked with affirming several key pieces of information before proceeding with excess line placements. Firstly, it collects basic data on the producing broker, including their license number and contact information, setting the stage for further attestations. Crucially, it demands brokers confirm whether they have provided the insured with a written Notice of Excess Line Placement, adhering to Section 2118 of the New York Insurance Law and Regulation 41. Additionally, the form delves into declination information, probing whether specific declinations are necessary for the type of risk at hand or if the insured qualifies as an "Exempt Commercial Purchaser." Brokers must document attempts to place the coverage with authorized New York insurers and note any reasons provided for declination. The requirement for brokers to underpin their submission with an affirmation under penalty of perjury ensures the accuracy and honesty of the information provided. Thus, the NYSID 41C W form embodies a key procedural step in safeguarding the integrity of the excess line insurance market in New York, promoting transparency and compliance within the industry.

QuestionAnswer
Form NameNYSID Form 41C-W
Form Length2 pages
Fillable?Yes
Fillable fields45
Avg. time to fill out9 min 34 sec
Other namespart c affidavit by producing broker fillable, licensee, nysid form 41c w, 41C

Form Preview Example

PART C – AFFIDAVIT BY PRODUCING BROKER

1. PRODUCING BROKER INFORMATION

 

AFFIDAVIT NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

License No. BR-

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

City

 

 

 

State

 

Zip Code

2.RISK INFORMATION:

Name of the Insured

(The name of the insured must be precisely the same in this affidavit and the declarations page, binder, cover note or confirmation of coverage.

3. DISCLOSURE INFORMATION

Yes

No

Did you personally provide a written Notice of Excess Line Placement (Form: NELP/2011) to the insured as required by Section 2118 of the New York Insurance Law and Regulation 41?

4. DECLINATION INFORMATION

(a)Yes

No

Has the Superintendent determined that declinations are not required for this type ofrisk? IF ANSWER TO QUESTION (a) IS “YES”, SKIP QUESTIONS (b) AND (c) GO ON TOTHE AFFIRMATION SECTION.

(b)Yes

No

Does the insured qualify as an “Exempt Commercial Purchaser” that made a written request consistent with the requirements of New York Insurance Law Section 2118(b)(3)(F)? IF ANSWER TO QUESTION (b) IS “YES”, SKIP QUESTION (c) GO ON TO THE AFFIRMATION SECTION.

(c)Yes

No

Was the risk described above submitted by the producing broker to companies: (1) each authorized in New York to write coverages of the kind requested; (2) which the licensee has reason to believe might consider writing the type of coverage or class of insurance involved; and, (3) was such risk declined by each such company?

If the answer to QUESTION (c) above is “YES”, COMPLETE THE FOLLOWING SCHEDULE:

AUTHORIZED COMPANIES DECLINING THE RISK

1.Name of company

NAIC Code

The insurer declined to underwrite the risk because:

Date of Declin.:

1.

Insurer presently lacks adequate capacity to write this risk.

2.

Specific underwriting reason.

3. Other (Specify)

Affiliation of Representative:

Company Employee

Agent

Other (specify)

Name of Representative Declining Risk

I believed this insurer would consider underwriting this risk because:

Recent acceptance by the insurer of a risk, requiring that type of coverage or class of Insurance.

Advertising by the insurer or its agent indicating it entertains that type of risk/coverage.

Media communications (Newspapers, Trade Magazines, Radio) which indicate the insurer will underwrite that type of coverage.

Communications with other professionals, such as brokers, agents, risk managers, insurance department or ELANY Personnel indicating the insurer entertains such risks.

Any other valid basis you can document.

NYSID Form 41C - W (Ed. July 2011)

Page 1 of 2

PART C – AFFIDAVIT BY PRODUCING BROKER

AFFIDAVIT NO.

AUTHORIZED COMPANIES DECLINING THE RISK

2.Name of Company

NAIC Code

The insurer declined to underwrite the risk because:

Date Declin.:

1.

Insurer presently lacks adequate capacity to write this risk.

2.

Specific underwriting reason.

3. Other (Specify)

Affiliation of Representative:

Company Employee

Agent

Other (specify)

Name of Representative Declining Risk

I believed this insurer would consider underwriting this risk because:

Recent acceptance by the insurer of a risk, requiring that type of coverage or class of Insurance.

Advertising by the insurer or its agent indicating it entertains that type of risk/coverage.

Media communications (Newspapers, Trade Magazines, Radio) which indicate the insurer will underwrite that type of coverage.

Communications with other professionals, such as brokers, agents, risk managers, insurance department or ELANY Personnel indicating the insurer entertains such risks.

Any other valid basis you can document.

3.Name of Company

NAIC Code

The insurer declined to underwrite the risk because:

Date Declin.:

1.

Insurer presently lacks adequate capacity to write this risk.

2.

Specific underwriting reason.

3. Other (Specify)

Affiliation of Representative:

Company Employee

Agent

Other (specify)

Name of Representative Declining Risk

I believed this insurer would consider underwriting this risk because:

Recent acceptance by the insurer of a risk, requiring that type of coverage or class of Insurance.

Advertising by the insurer or its agent indicating it entertains that type of risk/coverage.

Media communications (Newspapers, Trade Magazines, Radio) which indicate the insurer will underwrite that type of coverage.

Communications with other professionals, such as brokers, agents, risk managers, insurance department or ELANY Personnel indicating the insurer entertains such risks.

Any other valid basis you can document.

AFFIRMATION

I,

 

, am the licensee or sublicensee of the named broker

in Section 1 of this affirmation and I hereby affirm under penalties of perjury that all of the

information contained herein is true to the best of my knowledge and belief.

Signature of Affiant

 

Date

NYSID Form 41C - W (Ed. July 2011)

Page 2 of 2

How to Edit NYSID Form 41C-W Online for Free

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This document needs some specific details; in order to ensure consistency, please bear in mind the guidelines directly below:

1. The New_York will require certain details to be inserted. Make certain the following fields are completed:

Part number 1 of filling in NYSID

2. Now that the last segment is done, you'll want to put in the required details in DECLINATION INFORMATION, a Yes, Has the Superintendent determined, IF ANSWER TO QUESTION a IS YES, b Yes, Does the insured qualify as an, request consistent with the, c Yes, Was the risk described above, authorized in New York to write, AUTHORIZED COMPANIES DECLINING THE, Insurer presently lacks adequate, NAIC Code, Specific underwriting reason Other, and Name of company The insurer in order to move forward further.

NYSID completion process detailed (part 2)

3. This 3rd section should be relatively straightforward, Name of company The insurer, Agent, Name of Representative Declining, Recent acceptance by the insurer, Advertising by the insurer or its, Media communications Newspapers, underwrite that type of coverage, Communications with other, department or ELANY Personnel, Any other valid basis you can, NYSID Form C W Ed July, and Page of - all these fields must be filled in here.

How to fill in NYSID part 3

It is possible to make a mistake when filling out the Communications with other, hence be sure to look again before you'll finalize the form.

4. Now begin working on this next segment! In this case you have all of these PART C AFFIDAVIT BY PRODUCING, AFFIDAVIT NO, AUTHORIZED COMPANIES DECLINING THE, Insurer presently lacks adequate, NAIC Code, Name of Company The insurer, Specific underwriting reason Other, Company Employee, Agent, Date Declin, Other specify, Name of Representative Declining, Recent acceptance by the insurer, Advertising by the insurer or its, and Media communications Newspapers fields to do.

Find out how to prepare NYSID part 4

5. Since you come close to the conclusion of the form, there are actually a few more requirements that must be met. In particular, Insurer presently lacks adequate, Specific underwriting reason Other, Name of Company The insurer, Company Employee, Agent, Other specify, Name of Representative Declining, Recent acceptance by the insurer, Advertising by the insurer or its, Media communications Newspapers, underwrite that type of coverage, Communications with other, department or ELANY Personnel, Any other valid basis you can, and AFFIRMATION must be filled out.

Stage number 5 of filling out NYSID

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