COMMONWEALTH OF PENNSYLVANIA INSURANCE DEPARTMENT
1609-PR (REV. 08/12)
(Must be included with SLL Affidavit type 1609-SLL/1609-PR)
Report of transactions with unlicensed insurer(s) in accordance with Section 1609 of Article XVI, Surplus Lines of the Insurance Company Law, Act
of May 17, 1921, P.L. 682, No. 284, as amended
DECLARATION BY PRODUCER
Description of Insured’s Operation:
Effective Dates
(term) of Coverage
*Total Insured Value ** General or Policy Aggregate ***If more than one location of risk, then give address with most exposure
I declare under the penalties provided for perjury, that I have made a diligent effort to procure the insurance coverage described
above from licensed insurers which are authorized to transact the kind of insurance involved and which provide, in the usual
course of business, coverage comparable to the coverage being sought and have been unable to procure said insurance. I have
documented a declination of coverage from at least three admitted insurers.
I further declare under the penalties provided for perjury, that at the time of presenting a quotation to the insured, the insured was
given notice in writing, either directly or through the producer, that:
The insurer with whom the insurance is to be placed is not admitted to transact business in this
Commonwealth and is subject to limited regulation by the Department; and in the event of the insolvency
of the insurer, losses will not be paid by the Pennsylvania Property and Casualty Insurance Guaranty
Association.
ALL applicable provisions of ARTICLE XVI of the Insurance Company Law (40 P.S. §991.1601 et seq.) and Title
31 PA Code, Chapter 124 have been or will be complied with.
License # of
Producer
Agency:
(Type or Print Name of Producer Agency)
(Type or Print Name of Individual Producer)
(Individual’s License No.)
(Signature of Producer)
Pennsylvania Surplus Lines Association
180 Sheree Blvd., Suite 3100
Exton, PA 19341
-Select Insured's Operation
