In navigating the complexities of procuring insurance in the state of New Jersey, especially when dealing with ineligible unauthorized insurers, the SLPS-8-AFF3 form emerges as a vital document. This form, crafted by the State of New Jersey Department of Banking and Insurance's Surplus Lines Examining Office, serves as a supplemental certification by surplus lines agents. It plays a critical role for individuals or entities seeking to obtain insurance coverage through non-traditional means. Specifically, it is used when the insurance is sourced from insurers not authorized to operate within New Jersey but have been deemed acceptable by virtue of security deposits held by the Commissioner for the protection of policyholders in the state. The agents, by filling out this form, assert that the insurance coverage obtained cannot be procured from insurers within the admitted market. They must duly report the details of the insured, the coverage obtained, and the ineligible unauthorized insurer involved in the transaction. Each step and declaration made on the form is underscored by the legal requirement for honesty, with the acknowledgment that any willful falsification comes with potential civil and criminal repercussions. The form not only ensures compliance with the state's regulatory framework but also safeguards the interests of New Jersey policyholders by promoting transparency and accountability in the procurement of surplus lines insurance.
| Question | Answer |
|---|---|
| Form Name | Slps 8 Aff3 Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | fillabel nj certification of effort, new jersey certificate of effort fillable, nj certificate of effort, sample surplus lines forms |
Form Number |
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Transaction Number |
STATE OF NEW JERSEY
DEPARTMENT OF BANKING AND INSURANCE
SURPLUS LINES EXAMINING OFFICE
P.O. BOX 325
TRENTON, NEW JERSEY
SUPPLEMENTAL CERTIFICATION BY SURPLUS LINES AGENT FOR PROCEDUREMENT OF INSURANCE FROM INELIGIBLE UNAUTHORIZED INSURER
(Name of Insured)
(Street Address) |
(City or Town) |
(State) |
(Zip Code) |
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(Location of Property or Risk) |
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(Street Address) |
(City or Town) |
(State) |
(Zip Code) |
(Insurance Coverage) (Type of Coverage) (Policy Limits)
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(Name of Surplus Lines Agent Representing Insured Above)
(Title of Representative for Corporation or Partnership)
(Name of Business, Corporation or Partnership)
(Street Address) |
(City or Town) |
(State) |
(Zip Code) |
The above named individual is duly licensed as an insurance producer with surplus lines authority pursuant to N.J.S.A.
SUPPLEMENTAL CERTIFICATION BY SURPLUS LINES AGENT FOR PROCEDUREMENT OF INSURANCE FROM INELIGIBLE AUTHORIZED INSURER (continued)
Page 2 of 2
Name of Ineligible Unauthorized Insurer that business was placed with:
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NAIC # |
ISI # |
1. |
_____________________________ |
_____________ |
_______________ |
2. |
_____________________________ |
_____________ |
________________ |
3. |
_____________________________ |
_____________ |
________________ |
4. |
_____________________________ |
_____________ |
________________ |
Attach additional listings if needed.
The named ineligible unauthorized insurer has deposited with the Commissioner in accordance with N.J.S.A.
(I)(We) have procured from such ineligible unauthorized insurer and filed with the Commissioner a certified copy of its current annual statement of financial condition in accordance with N.J.S.A. 17:22- 6.45(h).
(I)(We) do not know of this coverage (s) being offered by companies I represent or by other companies in the admitted market.
(I)(We) certify that the foregoing statements made by me are true. I am aware that if any of the statements are willfully false, I am subject to civil and criminal penalties.
Name of Surplus Lines Agent
By: _______________________________________________________________________________
(Signature)
L:\Sections\OSR\Surplus