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Part c affidavit fillable

Part c affidavit by producing broker new york fillable 2026

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The document is an affidavit by a producing broker that outlines the necessary information regarding the insured, risk details, and disclosure requirements as mandated by New York Insurance Law. It includes sections for broker identification, risk assessment, declination of coverage by authorized companies, and an affirmation statement confirming the accuracy of the provided information.

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Click ‘Get Form’ to open it in the editor.
Begin with Section 1, where you will enter the Producing Broker Information. Fill in your Affidavit Number, License Number, Name, Address, City, State, and Zip Code.
Proceed to Section 2 for Risk Information. Ensure that the name of the insured matches exactly with the declarations page or confirmation of coverage.
In Section 3, answer the disclosure question regarding whether you provided a written Notice of Excess Line Placement. Select 'Yes' or 'No'.
Move to Section 4 for Declination Information. Answer questions (a), (b), and (c) as applicable. If necessary, complete the schedule for Authorized Companies Declining the Risk.
Finally, complete the Affirmation section by signing and dating it to confirm that all information is accurate.

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