New York State seal

February 23, 1981

SUBJECT: INSURANCE

WITHDRAWN

Circular Letter No. 5 (1981)

TO: ALL LICENSED EXCESS LINE BROKERS AND ALL PROPERTY AND CASUALTY INSURANCE COMPANIES

RE: FORMS REQUIRED BY REGULATION 41

Pursuant to Regulation 41, promulgated on November 25, 1980, attached are forms EL-1 and EL-2. Form EL-1 must be completed by the unauthorized insurer and form EL-2 by the Excess Line Broker. These forms should be reproduced as needed, but without any change. Form EL-1 will be required to be filed commencing with the end of calendar year 1981, and form EL-2 will be required to be used commencing March 1, 1981.

With reference to the affidavit required pursuant to Section 122 of the New York Insurance Law, please withhold the submission of said affidavits for policies with a 1981 effective date until a revised affidavit form is prescribed and sent to you.

Very truly yours,

[SIGNATURE]

Albert B. Lewis

Superintendent of Insurance

ATTACHMENT

Instructions

A separate column under "Names of Brokers" shall be used for each broker. This page should be reproduced as needed. Use as many pages as necessary to list all brokers your company does business with for property or risks located in the State of New York. The gross premium in each category is to be listed for each broker.

For alien insurers only, reporting on this form can be grouped into the five major groups as delineated below: 1-fire risks only; 2-all fire allied risks; 3-ocean marine risks; 4-all other property risks, and 5-all casualty risks. One figure next to the numbers 1 through 5 will be acceptable for alien insurers only.

When the New York broker or excess line broker is not known to the company filing this form, a list of insureds, arranged aphabetically with addresses, shall be permitted. This list shall indicate the gross premium for each insured.

Each company filing form EL-1 shall indicate the name and address of a person who may be contacted with reference to such form.

KINDS OF

Type of

 

NAMES OF BROKERS

INSURANCE

Ins. Code

           
 

Fire

1A

         
               
 

Allied lines on

2A

         
 

 Fire Policies

           
               
 

Homeowners Multiple

2B

         
 

 Peril (Excl. fire)

           
               
 

Commercial Multiple

2C

         
 

 Peril (Excl. fire)

           
               
 

Tornado, Wind, Cyclone,

2D

         
 

 Hail

           
               
 

Sprinkler and Water

2E

         
 

 Damage

           
               
 

Explosion, Riot and

2F

         
 

 Commotion

           
               
 

Earthquake

2G

         
               

3

Ocean Marine

3A

         
               

4

Inland Marine

4A

         
               
 

Aircraft Physical

4B

         
 

 Damage

           
               
 

Glass

4C

         
               
 

Animal

4D

         
 

Auto Physical Damage

4E

         
 

 (excl. fire)

           
               
 

Burglary & Theft

4F

         
               
 

Auto Collision

4G

         
               
 

Property damage

4H

         
 

 Other than Auto

           
               

5

Fidelity

5A

         
               
 

Surety

5B

         
               
 

Liability other

5C

         
 

 than Auto

           
               
 

Boiler & Machinery

5D

         
               
 

Elevator

5E

         
               
 

Auto Liability

5F

         
               
 

Auto Property Damage

5G

         
               
 

Errors & Omissions

5H

         
               
 

Worker's Comp.

5I

         
               
 

Contingent Commission

5J

         
               
 

Malpractice

5K

         
               
 

Credit Insurance

5L

         

Total

         

Contact Person: Name ______________________________

   Addresss ___________________________

   Telephone ________________________

(This form must be completed by the submitting broker or excess line broker and signed and dated by the company representative.)

I, ______________________ (Name), submitting broker or excess line broker, whose business address is __________________ (Street) _____________ (City) _______ (Zip) has submitted the risk hereinbelow described, to _____________________________________ (Name) _____________________________ (Address) an underwriter or agent having underwriting authority for the ____________________________ (Name of Company) a insurance company authorized to do an insurance business in the State of New York, hereby declares that on ______________, 19______, said risk was declined by the above-named underwriter or agent. The reason for declining said risk was: ____________________________________________ _________________________________________________________________

Name of Insured: _________________________________________________

Address of Insured: ___________________________Zip__________________

Type of Coverage Requested ______________________________________

_________________________________________________________________

_________________________________________________________________

(If more space is required attach additional sheets)__________________

Dated: ________________

Signed: __________________________________

submitting broker or excess line broker

I, the underwriter or agent having underwriting authority for the above-named company, confirm that the above information is correct.

Dated: ____________________

Signed: _______________________

underwriter or agent having underwriting authority

NOTE: INTENTIALLY GIVING FALSE INFORMATION ON THIS FORM IS TANTAMOUNT TO COMMITTING A PERJURY.