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Get Wv Due Diligence Form

Offices of the West Virginia Insurance Commissioner Due Diligence Form Form DDF Revised 8/09 New Renewal Rewrite Customer ID This form must be forwarded to the licensed surplus lines licensee placing the risk in the surplus lines market and must be retained in his or her office and may be examined at any time by the commissioner pursuant to W.Va. C. S* R* 114-20-4. 2 a and 114-20-4. 5. hereby submits that he/she is a duly licensed individual insurance producer under West Producer Name Type or Print Virginia Offices of the Insurance Commissioner license number Risk Description A Insured Name Type or Print B Address of Insured C Description of Risk D Location of Risk E Type of Coverage Street and Number City State Zip e*g* Laundromat Liquor Store. Do Not List Type of Coverage Is the type of coverage described on lines 2 C and 2 E on the current West Virginia Export List for both the type of insurance and the location in the State YES NO If you answered NO continue to Number 4 below. I declare under penalty of perjury that I have made a diligent search to procure the insurance coverage described above for licensed insurers in West Virginia which are authorized to transact the kind of insurance involved and which provide in the course of business coverage comparable to the coverage being sought. I have contacted the insurers that I represent customarily writing the find of insurance requested by the insured and have been unable to procure said insurance. The licensed insurers declining to insure this risk are as follows Full Name of Admitted Company NAIC Name of Company Representative and Telephone Number Date of Declination Code If Other was used as a Declination Code explain below NOTICE TO INSURED I have been expressly advised prior to the placement of the insurance that Insured Print or Type 1 The surplus lines insurer with which the insurance is placed is not an admitted authorized insurer in this State and is not subject to the Insurance Commissioner s supervision and 2 In the event the surplus lines insurer becomes insolvent claims will not be paid nor will unearned premiums be returned by any West Virginia guaranty fund. Signature of Insured Date The undersigned licensed individual insurance producer who performed or supervised the diligent search hereby certifies that this report is true and correct and that this risk is not being placed with a non-admitted insurer for the sole purpose of securing a rate or premium lower than the lowest rate or premium available from an admitted insurer. Licensed Individual Insurance Producer Print or Type Signature of Licensed Individual Insurance Producer. S* R* 114-20-4. 2 a and 114-20-4. 5. hereby submits that he/she is a duly licensed individual insurance producer under West Producer Name Type or Print Virginia Offices of the Insurance Commissioner license number Risk Description A Insured Name Type or Print B Address of Insured C Description of Risk D Location of Risk E Type of Coverage Street and Number City State Zip e*g* Laundromat Liquor Store. Do Not List Type of Coverage Is the type of coverage described on lines 2 C and 2 E on the current West Virginia Export List for both the type of insurance and the location in the State YES NO If you answered NO continue to Number 4 below.

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