FOR OFFICE USE ONLY:
ACCEPTED STAMP ONLY
MONTANA SURPLUS LINES SUBMISSION FORM
NOTICE: Complete entire submission form. Do not leave any blanks. Write “NA” if any question is “not applicable.” Incomplete submission forms will be returned.
INSURED: POLICY NUMBER:
MT ADDRESS: FILED ON A BINDER
Yes No
Part 1: Affirmation of Producing Insurance Producer Section
The undersigned hereby affirms that the insurance, which is subject to this affirmation, is in accordance with Title 33, Section 33-2-301 et seq., MCA, the Surplus Lines Insurance Law of the
State of Montana. The insurance which is the subject of this affirmation was not procured for: 1) The purpose of securing advantages as to the terms of the insurance contract and; 2) the
purpose of obtaining a lower premium rate than would be accepted by the authorized insurer except as provided in MCA 33-2-302 (2)(a)(iii)(A). Furthermore: 1) The insurance which is the
subject of this affirmation is a line of insurance which appears on the most recent Approved Risk List (ARL) issued by the Commissioner of Insurance; or 2) Immediately before requesting
from an unauthorized insurer the insurance which is the subject of this affirmation, I endeavored diligently and unsuccessfully to secure equivalent coverage from authorized insurers holding
certificates of authority to transact this line or the full amount of the line of insurance in the State of Montana. and; 3) I am aware that prior to placing the insurance that the surplus lines insurer
with whom the insurance is placed is not authorized in this state and is not subject to the same supervision as an authorized insurer; and in the event of the insolvency of the surplus lines
insurer, the property and casualty guaranty fund of the state will
not pay losses under the surplus lines coverage
Is the risk included on the most recent Approved Risk List? □ YES or □ NO If so, in which category? (Ex: GL-01)
If not included on the most recent ARL describe: 1) Type of Risk
1a) EXPLAIN in detail why insurance for this risk is unavailable from an authorized insurer: (COMPLETE SENTENCE)
2)
Indicate prior insurer: 2a) Explain why the prior insurer, if an authorized insurer, did not renew:
2b) If a renewal was offered, what was the renewal quote? (IF NONE PUT “NONE”)
3)
Are you filing using the 10%? MCA 33-2-302 (2)(a)(iii)(A) (Y or N ) (DILIGENT EFFORT IS REQUIRED)
4)
Is the insured an Exempt Commercial Purchaser? ___YES __NO, If “No” List a minimum of three authorized insurers you contacted for your diligent
efforts to place this insurance:
A. B. C.
$ $ $
I, , I am one and the same person whose name is subscribed below; that I have read the same and know the contents
thereof; and that the statement of facts contained herein are true.
Agency Name Address of Producing Insurance Producer
X
Signature of Producing Insurance Producer Date Montana Producer/Agency License #
PART 2: Montana Surplus Lines Insurance Producer Section
I, , affirm that: 1) I am the producer that placed this risk with the unauthorized insurer; 2) this line of insurance appears on the
most recent Approved Risk List (ARL) issued by the Commissioner of Insurance or that I have, to the best of my ability, attempted to place this line of
insurance through an authorized insurer and am unaware of any authorized insurer transacting this line or the full amount of this line of insurance in
Montana; and 3) I have complied with MCA 33-2-302.
Printed SL Agency Name or Independently Procured Insured Name Address of SL Agency
X #
Signature of SL Lines insurance producer Date MT Surplus Lines License #
PART 3: Premium / Tax / Fee Information Section- Montana is the Home State – no filing required if MT is not the home state
Name of Unauthorized Insurer(s): Lloyds Syndicate #
Policy Period From: To: Limits of Coverage: $
If this policy is a multi-year policy with the policy term greater than 12 months, this form is to be completed only in the initial year of the policy. For all
Subsequent years report policy premium on the Montana Surplus Lines Multi-Year Policy Premium Form
Policy Premium: $
Premium Tax: (2 .75%) $
Stamping Fee is 0% if filed electronically:
Personal Lines Surplus Lines Agent fee: $
NOTICE: Effective on July 1, 2015, Montana law allows the surplus lines agent to charge up to a $50 tax free fee for personal lines and up to a
$100 tax free fee for commercial lines for new and renewal business. Inspection fees for the actual cost of inspecting the risk to be reported on
the line above.
IF FILING ON PAPER SEND: THE ORIGINAL SUBMISSION PLUS 1 COPY AND 1 COPY OF DECLARATION PAGES AND/OR 1 COPY OF THE
BINDER. SEND TO: COMMISSIONER OF SECURITES AND INSURANCE AT 840 HELENA AVENUE, HELENA, MT 59601
Fire Premium*: $
Fire Tax (2.50%): $
Inspection Fee: $
Commercial Lines Surplus Agents Fee $
(If YES, you are affirming: 1. I have provided the insured with the disclosure information required by statute. 2. The unauthorized market quote was placed with a surplus lines
company that is “A” rated or better. 3. The authorized market quote(s) that were used were the lowest premium from the diligent effort. 4. The difference between the
authorized market quote(s) and the unauthorized market quote(s) meets the 10% requirement. 5. I listed the lowest quotes obtained from the authorized market search in #4
below.)
