Surplus Lines Statement - Ohio Department of Insurance - insurance ohio 2025

1. Click ‘Get Form’ to open the Surplus Lines Statement in the editor.
2. In Part 1, enter your name as the Surplus Line Broker or Originating Agent. Confirm your licensing status and provide details about the insurance policy you are unable to procure from authorized insurers.
3. List the insurers you approached for coverage in the designated section, along with reasons for their declinations. This ensures compliance with due diligence requirements.
4. Sign and date the form at the bottom of Part 1 to validate your statements.
5. In Part 2, have the named insured acknowledge their understanding that the policy will be placed with an unauthorized insurer. They must also sign this section.
6. Review all entries for accuracy before saving or exporting your completed form directly from our platform.

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