Certification of Effort To Place Risk With Authorized Insurer (continued)
Page 2 of 2
The following insurers are among those that I contacted relative to this risk, or to substantially similar risks
within the past 30 days:
INSURER REPRESENTATIVE TELEPHONE NO. DATE RESULTS
CODE*
_______________ __________________ ________________ _________ _______________
_______________ __________________ ________________ _________ _______________
_______________ __________________ ________________ _________ _______________
*Result Codes: (enter appropriate code(s) for each insurer listed above)
A. – Having made a diligent effort. I was unable to obtain an offer/quote from this authorized insurer
in the admitted market, which declined to accept all or any part of the risk.
AND/OR
B. -- Having made a diligent effort, the only offer (s)/ quote(s) obtained reflected such a substantial
increase in premium over similar coverage placed within the preceding 12 months that comparable
coverage is, as a practical matter, unavailable from this authorized insurer in the admitted market.
AND / OR
C. -- Having made a diligent effort. , the only offer (s)/ quote(s) obtained reflect(s) such a substantial
reduction in coverage from coverage placed within the preceding 12 months for substantially
similar premium that comparable coverage is, as a practical matter, unavailable from this
authorized insurer in the admitted market.
I certify that the foregoing statements made by me are true to the best of my knowledge and belief. I
am aware that if any of the statements are willfully false, I am subject to civil and criminal penalties.
________________ _______________________________________
(Date) (Signature)
Amended by R.2005 d.104, effective April 4, 2005.
See: 36 N.J.R.2144(a), 37 N.J.R.1065(a).
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