New York State seal

February 26, 1981

SUBJECT: INSURANCE

WITHDRAWN

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,

[SIGNATURE]

Albert B. Lewis

Superintendent of Insurance

ATTACHMENT

(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)____________________

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