Form INS. 311
STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
AFFIDAVIT BY BROKER
TO THE INSURANCE COMMISSIONER: I (we)…………………………………………………………………………………………, being duly sworn deposes and says that I (we) am/are a licensed Surplus Line Broker in accordance with the provisions of Chapter 27-3 of the General Laws of Rhode Island, as Amended, with an office at ….………………………………………………………………………………………………………………………. (Street) (City or Town) (State) On…………………………, 20………as a licensed Surplus Line Broker, I (we) was/were engaged by the insured named herein either directly or by a licensed Rhode Island producer to obtain insurance against certain risks covering property as described below; said insured or his/her producer was * (able to effect only part of) (unable to effect any part of) the required insurance with insurers licensed to transact business in the State of Rhode Island as follows: $………………………………………………………………………………………………………………………….
(Fill in here type of insurance and amount)
and that diligent effort has been made on behalf of the insured to procure the full amount of insurance from insurers licensed to insure these risks in the State of Rhode Island. The following licensed insurer (s) and officer (s) or producer (s) thereof are among those which have declined the offering or accepted a part thereof: 1.………………………………………………………………………………………………………………………... 2.………………………………………………………………………………………………………………………… 3...……………………………………………………………………………………………………………………… The licensed Surplus Line broker has effected the insurance shown on the reverse side with certain approved surplus lines insurer (s) as indicated on the reverse side. Such insurance was only the excess, over the amounts procurable, if any, from insurers licensed to do business in Rhode Island. Personally appeared before me
…………………………………………….. ………...……………………………………. (Signature of Surplus Line Broker)
and made oath that the above affidavit signed by him/her is true to the best of his knowledge and belief. ……………………………………………..
(Notary Public)
………………….
(Date)
AFFIDAVIT BY INSURED
……………………………………………… of …………………………………………………………….………… (Name of Insured) (Street) (City or Town) (State) being duly sworn, depose and says that on ………………………………………, 20……….., I (we) directed my/our
insurance producer to obtain insurance against certain risks covering property as described on the reverse side; that my/our insurance producer informed me/us that * (only part of) (no part of) the required insurance could be obtained from insurers licensed to transact business in the State of Rhode Island, to wit: $………………………………………………………………………………………………………………
……………………………………………………………………………………………………………….………….. that he (she) informed me (us) that he (she) made diligent effort to procure the full amount of insurance from licensed insurers, but were unable to do so. *Strike out portion that does not apply
The following licensed insurer (s) and officer (s) or producer (s) thereof are among those which have declined the offering or accepted a part thereof:
1.…………………………………………………………………………………………………………….. 2.……………………………………………………………………………………………………………. 3...…………………………………………………………………………………………………………… I (we) were further informed that the amount of insurance shown below could be obtained from certain approved surplus lines insurer (s) not licensed to transact business in the State of Rhode Island. I (we)
therefore directed………………………………………………………a licensed Rhode Island producer to obtain said insurance from such approved surplus lines insurers through the office of…….....………………………………………………………………………a licensed Surplus Line Broker. Such insurance was only the excess, over the amounts procurable, if any, from licensed insurers.
Personally appeared before me
……………………………………
and made oath that the above affidavit signed by him/her is true to the best of his/her knowledge and belief …………………………………………
Signature of Insured
………………………………………………. (Notary Public)
………………….
(Date)
NOTICE THIS INSURANCE CONTRACT HAS BEEN PLACED WITH AN INSURER NOT LICENSED TO DO BUSINESS IN THE STATE OF RHODE ISLAND BUT APPROVED AS A SURPLUS LINES INSURER. THE INSURER IS NOT A MEMBER OF THE RHODE ISLAND INSURERS INSOLVENCY FUND. SHOULD THE INSURER BECOME INSOLVENT, THE PROTECTION AND BENFITS OF THE RHODE ISLAND INSURERS INSOLVENCY FUND ARE NOT AVAILABLE. Name of Insured: _____________________________________________________________________________ Location of Risk: _____________________________________________________________________________ Kind of Insurance**: ________________________________ Amount of Insurance: _______________________ Name and Address of Approved Surplus Lines Insurer: _______________________________________________
Policy Term and Expiration Date: _________________________________________________________________ Policy Number: ___________________________________ Premium:____________________________________ Name of Surplus Line Broker: ____________________________________________________________________ License Number: ______________________________________________________________________________ IMPORTANT ** If coverage afforded herein provides for automobile bodily injury and/or property damage liability insurance and/or physical damage insurance, one of the following must be attached:
(1)
Declination issued either by the Rhode Island Automobile Insurance Plan or by the carrier assigned by the Plan. Said declination must declare the applicant ineligible for coverage by the Plan; or A copy (certified) of the individual’s Motor Vehicle Report showing him/her to be ineligible for automobile coverage; or An itemized account showing the surplus rates to be less than the Plan.
(2)
(3)
(Form #311 Amended as of 10/2000)