NOTICE:
The language and format of this Form shall not be altered. Issued: July 15, 2015
LOUISIANA DEPARTMENT OF INSURANCE
FORM 438
ACKNOWLEDGEMENT OF APPLICANT FOR PERSONAL LINES
INSURANCE COVERAGE IN THE SURPLUS LINES MARKET
______________________________
I am applying for personal lines insurance coverage in the surplus lines market. By
placing my initials on the four (4) statements below, and dating and signing this
form, I hereby acknowledge the following in accordance with La. R.S. 22:438, to wit:
_____
initial
The insurance may be placed with a surplus lines insurer.
initial
In the event of insolvency of the insurer, losses shall not be paid by the
Louisiana Insurance Guaranty Association.
initial
I expressly authorize the procurement of surplus lines insurance coverage.
initial
Any surplus lines coverage shall be procured through a duly licensed
surplus lines broker.
___________________
Signature of Applicant
________________________
Printed Name of Applicant
Date
Name of Property & Casualty Producer:___________________________________
Address: ___________________________________________________________
City: _______________________________ State: ______________ Zip:_________
This form shall be maintained by the surplus lines broker.
