INS4024 Surplus Lines Statement: Fill out & sign online

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Click ‘Get Form’ to open the INS4024 Surplus Lines Statement in the editor.
In Part 1, enter the name of the surplus line broker or originating agent in the designated field. Ensure that you confirm your licensing status as a full multiple line agent or surplus line broker.
Fill in the property or risk to be insured in the provided space. This is crucial for clarity on what coverage is being sought.
List any insurers from whom you sought coverage and provide reasons for declination. This section helps demonstrate due diligence.
Sign and date the form at the bottom of Part 1 to validate your statements.
In Part 2, have the named insured acknowledge their understanding of placing insurance with a non-authorized company by filling in their name and signing where indicated.

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What is an example of a surplus line?

Regular insurance carriers, also called standard or admitted carriers, must follow state regulations concerning how much they can charge and what risks they can and cannot cover. Surplus lines carriers do not have to follow these regulations, which allows them to take on higher risks.

How to explain surplus lines insurance?

Surplus line insurance is coverage for higher risks, such as a: Home built on the side of steep bank or an extremely old home. Very expensive racehorse. Rare art or antique collection. Custom-made yacht. Business operation that poses too great a liability risk.

How does surplus line tax work?

What is Surplus Lines Tax? Surplus lines tax is a type of tax that is imposed on insurance policies that are not covered by the states admitted insurance market. This means that the insurance policy is not regulated by the states insurance department and is instead placed with a non-admitted insurance company.

How to explain surplus line tax?

SURPLUS LINES TAXES Most states charge an insurance premium tax to insurance companies licensed and admitted to do business within their borders. Generally speaking, those carriers then pass the cost of those taxes onto their policyholders by adding a comparable amount to their premiums.