Address:
1.
.
.
MM/DD/YYYY Format
Furthermore, this insurance was not exported for the purpose of securing lower rates than would be accepted by an
authorized insurer or because of the term of the contract.
MM/DD/YYYY Format
Among the licensed insurers declining to insure this risk or declining to increase the amount of insurance on this risk,
are the following:
Name & Telephone # of Contact:
DESCRIPTION OF COVERAGE:
ro
ucer
ro
er
Signature
DE Lic # of
Agency
DE Lic #
Individual
(Type or print name of Individual)
(Type or print name of Agency)
Name of Agency
POLICY NUMBER
INSURED'S NAME AND MAILING ADDRESS:
I further attest that I have explained to the insured that the insurance described herein is being placed with an
insurance company not authorized to do business in Delaware. The insured understands that the insurance company is
not a member of the Delaware Insurance Guaranty Association and that Chapter 42 of the Delaware Insurance Code is
not applicable to claimants or insureds of said company. As required in 18 Del. C., §1909, I have delivered to the
insured evidence of the insurance upon which has been stamped:
Name & Telephone # of Contact:
Reason for Declining:
Expiration Date
POLICY TERM INFORMATION
Name of Producer/ SL
Broker
Name & Telephone # of Contact:
Property
Name & NAIC # of Insurer:
Effective Date
Reason for Declining:
LOCATION OF RISK
CasualtyAMOUNT OF INSURANCE
Name:
RETAIN AS PART OF SURPLUS LINES BROKER RECORDS
THIS FORM MUST BE OPEN TO EXAMINATION BY THE COMMISSIONER AT ALL TIMES FOR 5 YEARS AFTER ISSUANCE OF THE COVERAGE TO WHICH IT RELATES. (18 DEL. C., §1915)
"This insurance contract is issued pursuant to the Delaware Insurance Laws by an insurer neither licensed by
nor under the jurisdiction of the Delaware Insurance Department. This insurer does not participate in
insurance guaranty funds created by state law. In the event of the insolvency of the surplus lines insurer, losses
will not be paid by the state insurance guaranty fund."
ame
o
nsurer:
Reason for Declining:
I declare that I have procured the insurance coverage here described pursuant to Chapter 19 of Title 18, the Delaware
Insurance Code, and that the information contained in this submission is true.
THIS FORM MUST SIGNED BY THE LICENSED PRODUCING AGENT AND FORWARDED TO THE LICENSED SURPLUS LINES BROKER OR SIGNED AND RETAINED BY THE SL
Formerly Form SL-1904
ame & NAIC # of Insurer:
I declare under the penalties provided by law that I have made a diligent effort to procure the insurance coverage
described above from licensed insurers which are authorized to transact the class of insurance involved and which
accept, in the usual course of business, insurance on risks of the same class as the risk described above. Having been
unable to secure such coverage, I have resorted to coverage with companies not licensed to operate in the State o
Delaware and which are not under the jurisdiction of the Insurance Department of the State of Delaware.
STATEMENT OF DILIGENT EFFORT
SURPLUS LINES INSURER NAME
Form SL-1923
Submitted by: (select one)
SURPLUS LINES
DO NOT SUBMIT THIS FORM TO THE INSURANCE DEPARTMENT
NAIC #
SL BROKER
PRODUCER
Form SL-1923 (Formerly Form SL-1904) Effective 2012 Direct any questions to: Ann.Fletcher@state.de.us
click to sign
signature
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