Slps 8 Aff3 Form PDF Details

Do you need to submit an SLPS 8 Aff3 form, but don't know where to start? If so, then this blog post is for you! Here we'll walk through the process of understanding and properly preparing your SLPS 8 Aff3 form. We'll cover everything from what information is needed to how and when this should be completed. With this guide in hand, you'll easily be able to get your application submitted with confidence knowing that all necessary components have been included. Read on for more details about the SLPS 8 Aff3 submission process.

QuestionAnswer
Form NameSlps 8 Aff3 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesfillabel nj certification of effort, new jersey certificate of effort fillable, nj certificate of effort, sample surplus lines forms

Form Preview Example

Form Number SLPS-8-AFF3

/__/__/__/__/__/ - /__/__/ - /__/__/__/__/__/

 

Transaction Number

STATE OF NEW JERSEY

DEPARTMENT OF BANKING AND INSURANCE

SURPLUS LINES EXAMINING OFFICE

P.O. BOX 325

TRENTON, NEW JERSEY 08625-0325

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)

 

 

 

 

(Location of Property or Risk)

 

 

 

 

 

 

 

(Street Address)

(City or Town)

(State)

(Zip Code)

(Insurance Coverage) (Type of Coverage) (Policy Limits)

///////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////

(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. 17:22-1 et seq.

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:

 

 

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. 11:2-32, securities in the amount acceptable to the Commissioner, which are held by the Commissioner for the benefit of New Jersey policy holders; and

(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 Lines\Forms\SLPS-8-AFF3-(2005).doc