It has come to our attention that the revised SL-1 Form distributed under cover of Bulletin #693, dated April 12, 1995, contained a typographical error. The error is on Page One, Item #2, Risk Description, letter (E), "Type of Insurance Coverage." Please note, tile page number referenced in parentheses should read "Page 2." Attached is a replacement copy of Page One of the revised SL-1 Form for your records.
We apologize for any inconvenience this may have caused. Should You have questions or concerns, please let us know.
Edgar S. Clark
Executive Director
Policy Number: Calif. Premium:
CONFIDENTIAL REPORT OF SURPLUS LINE PLACEMENT
Please refer to the instructions on Page 2. This form must be accompanied by
a diligent
search report and a copy of the declarations page or certificate or binder.
(California Insurance Code Section 1763 (a)
_______________________________________________hereby submits
that he/she is:
(A) A duly licensed surplus line broker, license number___________________________
or (B)A transactor on the surplus line license of_________________________________
(Name of Organization)
________________________________________, license number______________________
and (C) that he/she or said organizational licensee was engaged by the insured,
or the
insured's broker, named herein, to obtain insurance against certain risk as
described in this report.
2. RISK DESCRIPTION
3.
(A) Name of Insured_________________________________________________________
(B) Address of Insured____________________________________________________________________
(Street and Number)
(City) (State) (Zip Code)
(C) Description of the Risk__________________________________________________________________
(e.g. Laundromat, Liquor Store, NOT TYPE OF COVERAGE)
(D) Location of the Risk____________________________________________________________________
(Street and Number)
(City) (State) (Zip Code)
(E) Type of Insurance coverage______________________________________________________________
(Enter Appropriate Code Number-See Codes on Page 2)
3. PLACEMENT DESCRIPTION
List Nonadmitted Insurer(s) Underwriting This Policy with % of Premium. (Include
an attachment if additional space is needed or attach a line slip) If GAP provision
applies, please include GAP Exemption Form-Attachment.
NAME OF NONADMITTED INSURER(S) % OF PREMIUM_
____________________________________ ________________
____________________________________ ________________
____________________________________ ________________
_______________________________ ____________
(Signature of Person Named on Line 1) (Date)