Surplus Lines Broker Forms-Updated 7-2-2023

Department of Business Regulation Insurance Division 1511 Pontiac Avenue, Bldg. 69-2 Cranston, Rhode Island 02920 Insurance Bulletin Number 2018-9 Surplus Lines Broker Forms The following forms are designated for use in compliance with 230-RICR-20-50-1- Surplus Lines Brokers. Section 1.6 Affidavits Affidavit by Broker Affidavit by Insured Section 1.7 Annual Report Annual Surplus Lines Report, due April 1st Updated July 2023 2 STATE OF RHODE ISLAND swear AFFIDAVIT BY BROKER I under penalty of perjury as follows. I am a Surplus Lines Broker licensed pursuant to R.I. Gen. Laws §§ 27-3-1 et seq. with an office at: ______________________________________________________________________ (street) (city or town) (state) (zip code) The following information is true and correct and made in conjunction with my responsibilities as a licensed Surplus Lines Broker. On _________________________, 2____, as a licensed Surplus Lines Broker, I was engaged by the insured named herein, either directly or by a licensed Rhode Island producer, to obtain insurance against the risk described in this document. A diligent effort has been made, but neither the insured nor their producer were able to obtain the required insurance with insurers licensed to transact business in the State of Rhode Island. The following insurers, licensed to write the type of insurance which is the subject of this affidavit within the State of Rhode Island, have declined the risk described (please note that the underwriter or producer who declined the risk must be identified): Insurer Underwriter or Producer who Declined Risk 1. _____________________________________________________________ 2. _____________________________________________________________ 3. _____________________________________________________________ As a licensed Surplus Lines Broker I have obtained the insurance from the surplus lines insurer indicated at the bottom of the second page of this form. I hereby certify under penalty of perjury that the foregoing is true and correct. ____________________________________ Surplus Lines Broker Page 1 of 2 (Affidavit) 3 AFFIDAVIT BY INSURED I _______________________________________________________of ______________________________________________________________________ (street) (city or town) (state) (zip code) state that on _________________________, 2____, I directed ______________________________________________, a licensed Rhode Island insurance producer, to obtain insurance against the risk as described below. They informed me that the required insurance could not be obtained from insurers licensed to transact business in the State of Rhode Island. They also informed me that they made a diligent effort to procure the insurance from licensed insurers, but were unable to do so. I therefore directed the insurance producer to obtain said insurance from such approved Surplus Lines Insurers through the office of _______________________________________, a licensed Rhode Island Surplus Lines Broker. 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 BENEFITS OF THE RHODE ISLAND INSURERS INSOLVENCY FUND ARE NOT AVAILABLE. __________________________________ Insured Risk Insured: Line of Business: Amount of Insurance: Name of Approved Surplus Lines Insurer: Policy Number, Term and Expiration Date: Premium: Surplus Lines Broker License Number: Page 2 of 2 (Affidavit) Updated July 2023 4 STATE OF RHODE ISLAND DEPARTMENT OF BUSINESS REGULATION Division of Insurance 1511 Pontiac Blvd., Bldg. 69-2 Cranston, Rhode Island 02920 www.dbr.ri.gov 230-RICR-20-50-1 Annual Surplus Lines Report Due April 1 Calendar Year 2_______ Name of Surplus Lines Broker: Address of Surplus Lines Broker: Total Surplus Lines Insurance Policies Written in 2_________ : __________ Total Surplus Lines Premium Written in 2____________: ______ __ Risk Insured Line of ______________________ Business * Amount of Insurance Name of Surplus Lines Insurer Policy Number Term and Expiration Date Premium * Line of Business to be reported as homeowners, personal flood, commercial property, commercial flood, commercial auto physical damage, medical malpractice, general liability, other professional liability, cyber, other personal, other commercial, or disability income. Updated July 2023