Florida Surplus Lines Service Office
9
th
Revision - Revised 09/06
168
STATEMENT OF DILIGENT EFFORT
Producing Agent__________________________________________ License Number _____________________
Name of Agency_____________________________________________________________________________
Has sought to obtain:
Type of Coverage __________________________________________________________________________ for
Named Insured _____________________________________________________from the following authorized insurers
currently writing this type of coverage:
(1) Authorized Insurer _________________________________ Person Contacted _____________________________
Telephone Number_____________________ Date of Contact _____________________________________________
The reason(s) for declination by the insurer was (were) as follows:
________________________________________________________________________________________________
(2) Authorized Insurer __________________________________ Person Contacted ____________________________
Telephone Number_______________________ Date of Contact __________________________________________
The reason(s) for declination by the insurer was (were) as follows:
_______________________________________________________________________________
(3) Authorized Insurer ________________________________ Person Contacted _____________________________
Telephone Number
________________________ Date of Contact _________________________________
The reason(s) for declination by the insurer was (were) as follows:
_______________________________________________________________________________
_______________________________________________________________________________
Signature of Producing Agent Printed or Typed Name of Producing Agent
Document Verified by Surplus Lines Agent: Yes ___ No ____ Date Verified: _________________
DI4-1153
7/00
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