NYSID Form 41C-W – Fill Out and Use This PDF

Enter the AFFIDAVIT NO., the License No. BR-, and the Name, Address, City, State and Zip Code under PRODUCING BROKER INFORMATION.

Enter the 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.

Mark Yes or 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?

For question (a), mark Yes or No: Has the Superintendent determined that declinations are not required for this type of risk? If the answer to question (a) is “YES”, skip questions (b) and (c) and go on to the affirmation section.

For question (b), mark Yes or 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 the answer to question (b) is “YES”, skip question (c) and go on to the affirmation section.

For question (c), mark Yes or No: Was the risk 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) is “YES”, complete the schedule.

Under AUTHORIZED COMPANIES DECLINING THE RISK, enter for company 1 the Name of company, the Date of Declin. and the NAIC Code.

Mark the basis for 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.

For company 2 and for company 3, enter the Name of Company, the Date of Declin. and the NAIC Code, and mark the basis for I believed this insurer would consider underwriting this risk because.

Enter the AFFIDAVIT NO. under PART C - AFFIDAVIT BY PRODUCING BROKER.

After I, enter the name of the Affiant, the licensee or sublicensee of the named broker in Section 1 of this affirmation. Affirm under penalties of perjury that all of the information contained herein is true to the best of my knowledge and belief.

Sign on the Signature of Affiant line and enter the Date.