New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 1 - ADMINISTRATION
Subchapter 33 - SURPLUS LINES INSURANCE: PROCUREMENT PROCEDURE
Appendix - APPENDIX
Exhibit A
EXHIBIT A-1
Form to be used at the time of quotation:
The undersigned applicant has been advised by the undersigned originating insurance producer and understands that an insurance policy written by a surplus lines insurer is not subject to the filing or approval requirements of the New Jersey Department of Banking and Insurance. Such a policy may contain conditions, limitations, exclusions and different terms than a policy issued by an insurer granted a Certificate of Authority by the New Jersey Department of Banking and Insurance.
| .......................................................... |
| Applicant's Signature |
| .......................................................... |
| Applicant's Name (Print or Type) |
| .......................................................... |
| Date of Applicant's Signature |
| .......................................................... |
| Producer Signature |
| .......................................................... |
| Producer Name (Print or Type) |
| ................................................. |
| Date of Producer Signature |
| .......................................................... |
| New Jersey Producer License Reference Number |
EXHIBIT A-2
Statement to Appear on all Surplus Lines Policies, Evidence of Coverage and Renewal Policies or to be provided or as a stand alone notice:
This policy is written by a surplus lines insurer and is not subject to the filing or approval requirements of the New Jersey Department of Banking and Insurance. Such a policy may contain conditions, limitations, exclusions and different terms than a policy issued by an insurer granted a Certificate of Authority by the New Jersey Department of Banking and Insurance. The insurer has been approved by the Department as an eligible surplus lines insurer, but the policy is not covered by the New Jersey Insurance Guaranty Fund, and only a policy of medical malpractice liability insurance as defined in N.J.S.A. 17:30D-3d or a policy of property insurance covering owner-occupied dwellings of less than four dwelling units are covered by the New Jersey Surplus Lines Guaranty Fund.
