DELAWARE DEPARTMENT OF INSURANCE
SURPLUS LINES FORM SL-1914
EXEMPT COMMERCIAL PURCHASER APPLICATION
(References are to Title 18, Delaware Insurance Code)
THIS SIGNED FORM MUST BE RETAINED BY THE SURPLUS LINES BROKER WITH
THE RECORDS FOR THE POLICY TO WHICH IT PERTAINS.
The broker’s records shall be open to examination by the Commissioner at all times within five years after issuance
of the coverage to which it relates pursuant to § 1923 (b).
I, the undersigned, am an “exempt commercial purchaser,” as defined in 18 Delaware Code § 1914; therefore,
application is being made to procure insurance through an insurance company that is not licensed in Delaware.
I understand that the insurance company with which this coverage has been placed is not licensed by the State of
Delaware and is not subject to its jurisdiction, and that in the event of the insolvency of the insurance company,
losses under this policy will not be paid by any State insurance guaranty or solvency fund.
The broker procuring or placing the surplus lines insurance has disclosed to me that such insurance may or may
not be available from the admitted market that may provide greater protection with more regulatory oversight.
I hereby request in writing that the licensee procure or place such insurance from a nonadmitted insurer.
____________________________________
Date Signature of Applicant (Insured)
Printed Name of Applicant
APPLICATION FROM PRODUCING AGENT TO SURPLUS LINES LICENSEE
Application is made on behalf of __________________________________________________________________,
for insurance with an insurance company not licensed to do business in Delaware, as the applicant is an “exempt commercial
purchaser,” as defined in 18 Delaware Code § 1914.
____________________________________
Date Signature of Producing Broker
Pursuant to 18 Delaware Code § 1914 (a), I, (print name), a licensed surplus lines broker
under DE license #: , intend to place the insurance described below with an insurance company not
licensed to do business in Delaware on behalf of the above named exempt commercial purchaser without making a diligent
effort to determine whether the full amount or type of insurance sought by such exempt commercial purchaser can be obtained
from admitted insurers.
Surplus Lines
Policy
Address of
Description of
Amount of
Premium Charged
Policy Period
____________________________________
Date Signature of Surplus Lines Licensee
