Forms for Insurance Coverage for Lead Poisoning

Department of Business Regulation Insurance Division 1511 Pontiac Avenue, Bldg. 69-2 Cranston, Rhode Island 02920 Insurance Bulletin Number 2018-11 Forms Insurance Coverage for Lead Poisoning The following form is designated for use in compliance with 230-RICR-20-05-9: EXHIBIT A Information Concerning Lead Liability Coverage Name of Insurer: _______________________________________________________________ NAIC/Group Number: ___________________________________________________________ Calendar Year for Which Information is Reported: _____________________________________ Date of Submission: _____________________________________________________________ Identity of Person Completing Form (name and telephone number) ________________________ Each individual insurer must provide the following information regarding residential Rental Properties built prior to 1978. This information may not be reported on a group basis. The following information is for commercial lines only Policies in force covering Rental Properties: number _______________ direct written premium ________ Policies in force covering Rental Properties that exclude Lead Liability Coverage: number _______________ direct written premium ________ Number of Rental Properties for which notice of eligibility to the FAIR Plan was given: ______________ Average Premium for Commercial Lines including Lead Liability Coverage: _______________________ Average Premium for Commercial Lines excluding Lead Liability Coverage: _______________________ Number of Lead Liability Claims: ________ Settlements: _________ Judgments: _________ Total Lead Liability Claim Payments: __________________________ Does the insurer have underwriting rules restricting business based upon age or geographic location of risk? Yes □ No □ If the answer to the preceding question is in the affirmative, attach a copy of said rules to this form and indicate how such rules comply with R.I. Gen. Laws § 27-29-4 (iii) and (iv) and R.I. Gen. Laws §.27-29- 4.1. Prima Facie Evidence of Compliance (indicate whether the insurer is accepting or rejecting Rental Properties when the property owner provides one of the following forms of compliance) Certificate of Conformance (Lead Mitigation) - Accepting □ Rejecting □ Certificate of Compliance (Lead Safe) - Accepting □ Rejecting □ Certificate of Presumptive Compliance - Accepting □ Rejecting □ The following information is for personal lines only Policies in force covering Rental Properties: number _______________ direct written premium ________ Policies in force covering Rental Properties that exclude Lead Liability Coverage: number _______________ direct written premium ________ Number of Rental Properties for which notice of eligibility to the FAIR Plan was given: ______________ Average Premium for Personal Lines including Lead Liability Coverage: ___________________________ Average Premium for Personal Lines excluding Lead Liability Coverage: ___________________________ Number of Lead Liability Claims: ________ Settlements: _________ Judgments: _________ Total Lead Liability Claim Payments: __________________________ Does the insurer have underwriting rules restricting business based upon age or geographic location of risk? Yes □ No □ If the answer to the preceding question is in the affirmative, attach a copy of said rules to this form and indicate how such rules comply with R.I. Gen. Laws § 27-29-4 (iii) and (iv) and R.I. Gen. Laws §.27-29- 4.1.. Prima Facie Evidence of Compliance (indicate whether the insurer is accepting or rejecting Rental Properties when the property owner provides one of the following forms of compliance) Certificate of Conformance (Lead Mitigation) - Accepting □ Rejecting □ Certificate of Compliance (Lead Safe) - Accepting □ Rejecting □ Certificate of Presumptive Compliance - Accepting □ Rejecting □ EXHIBIT B Information Submitted by Surplus Lines Broker Regarding Lead Liability Coverage Name of Broker: _____________________________ Surplus Lines Broker License Number: ____________________________ Calendar Year ______________ Date Submitted: ________________________ The following information must be submitted regarding residential Rental Properties built prior to 1978. The following information is for commercial lines only Policies in force covering Rental Properties: number _______________ direct written premium ________ Policies in force covering Rental Properties that exclude Lead Liability Coverage: number _______________ direct written premium ________ Average Premium for Commercial Lines Policies including Lead Liability Coverage: _________________ Average Premium for Commercial Lines Policies excluding Lead Liability Coverage: _________________ Name of Approved Surplus Lines Insurer Number of Insurance Policies Written on Rental Properties The following information is for personal lines only Policies in force covering Rental Properties: number _______________ direct written premium ________ Policies in force covering Rental Properties that exclude Lead Liability Coverage: number _______________ direct written premium ________ Average Premium for Personal Lines Policies including Lead Liability Coverage:____________________ Average Premium for Personal Lines Policies excluding Lead Liability Coverage: ____________________ Name of Approved Surplus Lines Insurer Number of Insurance Policies Written on Rental Properties