DELAWARE DEPARTMENT OF INSURANCE
SURPLUS LINES FORM SL-1917
SURPLUS LINES BROKER NOTICE TO INSURED
(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).
Surplus Lines
I, (Print name), as surplus lines broker for the undersigned
insured, hereby notify the insured that :
a. The insurer with which the broker is placing the insurance is not licensed by this state
and is not under the jurisdiction of the Delaware Insurance Department; and
b. In the event of the insolvency of the surplus lines insurer, losses will not be paid by any
state insurance guaranty fund.
The insured is further notified that the policy forms, conditions, premiums and deductibles used
by surplus lines insurers may be different from those found in policies used by admitted insurance
companies.
Signature of Surplus Lines Broker Date
Receipt of the above notice, received prior to the placement of the above-referenced insurance coverage, is
hereby acknowledged by the above-named insured.
Signature of Insured Date
