February 26, 1981
Circular Letter No. 7 (1981)
TO: ALL LICENSED EXCESS LINE BROKERS AND ALL PROPERTY AND CASUALTY INSURANCE COMPANIES
RE: FORMS REQUIRED BY REGULATION 41
Circular Letter No. 5 (1981) dated February 23, 1981, contained copies of forms (EL-1 and EL-2) required by Regulation 41.
Please be advised that Form EL-2 contained a misspelling. The word "Intentially" in the "Note" on the bottom of the form should be "Intentionally".
Attached please find a corrected EL-2 Form which should be reproduced as needed.
Very truly yours,
Albert B. Lewis
Superintendent of Insurance
(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) an 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 clining said risk was:__________________________________________________ ____________________________________________________________________
Name of Insured: ___________________________________________________
Address of Insured: __________________________________Zip_____________
Type of Coverage Requested ________________________________________
(If more space is required attach additional sheets)____________________
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.
underwriter or agent having underwriting authority
NOTE: INTENTIONALLY GIVING FALSE INFORMATION ON THIS FORM IS TANTAMOUNT TO COMMITTING A PERJURY.