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Diligent Search Report

1.

I, 

, hereby submit that

I performed or supervised this diligent search, and I am:

 

(A) licensed as an individual agent-broker for the applicable lines of insurance or surplus line broker under California license number

(B) licensed and an endorsee on the license of 

, California license number

2.

(A) Name of Insured:

(B) Description of Risk:

(C) Type of Insurance or Coverage Code:

3.

Describe the diligent efforts made to place this coverage with admitted insurers by completing (A) or, if applicable, (B) below.

(A) List the insurers admitted in California who actually write the type of insurance described on lines 2(B) and 2(C) to which you or someone under your supervision submitted the risk described in lines 2(A) through 2(C). Please complete ALL sections of the table below.

Admitted Insurer 1

Full Name of Admitted Insurer/NAIC ID

Date of Declination

Contact Information

or

Admitted Insurer 2

Full Name of Admitted Insurer/NAIC ID

Date of Declination

Contact Information

or

Admitted Insurer 3

Full Name of Admitted Insurer/NAIC ID

Date of Declination

Contact Information

or

(B) If you did not list at least three insurers in 3(A) above, describe in detail how you determined that fewer than THREE admitted insurers write the type of insurance described on lines 2(B) and 2(C).

4.


Is the type of insurance you are reporting as identified in line 2(C) private passenger automobile liability or health?

Select an option

If you answered “yes,” please complete the Diligent Search Report Addendum.

The undersigned licensee 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.

Thank you!

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