ࡱ> ` bjbjss D   4\[\[\[\[\4L{ ^0PbPbPbPb/cfh#z%z%z%z%z%z%z$|hj~6Iz i+c/ciiIzPbPb{llliFRPb Pb#zli#zll" lPb^ Pc?\[jvlmd {0L{l~j2~l~ lliiiIzIzl iiiL{iiii44428"444844 PART C  AFFIDAVIT BY PRODUCING BROKER1. PRODUCING BROKER INFORMATION AFFIDAVIT NO.  FORMTEXT       FORMTEXT       FORMTEXT      License No. BR-  FORMTEXT      Name FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT      AddressCityStateZip Code2. RISK INFORMATION:Name of the Insured FORMTEXT      (The name of the insured must be precisely the same in this affidavit and the declarations page, binder, cover note or confirmation of coverage.3. DISCLOSURE INFORMATIONYes FORMCHECKBOX No FORMCHECKBOX Did you personally provide a written Notice of Excess Line Placement (Form: NELP/2011) to the insured as required by Section 2118 of the New York Insurance Law and Regulation 41? 4. DECLINATION INFORMATION(a)Yes FORMCHECKBOX No FORMCHECKBOX Has the Superintendent determined that declinations are not required for this type of risk?IF ANSWER TO QUESTION (a) IS YES, SKIP QUESTIONS (b) AND (c) GO ON TO THE AFFIRMATION SECTION.(b)Yes FORMCHECKBOX No FORMCHECKBOX Does the insured qualify as an Exempt Commercial Purchaser that made a written request consistent with the requirements of New York Insurance Law Section 2118(b)(3)(F)? IF ANSWER TO QUESTION (b) IS YES, SKIP QUESTION (c) GO ON TO THE AFFIRMATION SECTION.(c) Yes  FORMCHECKBOX  No  FORMCHECKBOX  Was the risk described above submitted by the producing broker to companies: (1) each authorized in New York to write coverages of the kind requested; (2) which the licensee has reason to believe might consider writing the type of coverage or class of insurance involved; and, (3) was such risk declined by each such company? If the answer to QUESTION (c) above is YES, COMPLETE THE FOLLOWING SCHEDULE:AUTHORIZED COMPANIES DECLINING THE RISK1.Name of company FORMTEXT      Date of Declin.: FORMTEXT      NAIC Code FORMTEXT      The insurer declined to underwrite the risk because:1. FORMCHECKBOX Insurer presently lacks adequate capacity to write this risk.2. FORMCHECKBOX Specific underwriting reason.3. FORMCHECKBOX Other (Specify) FORMTEXT      Affiliation of Representative: FORMCHECKBOX Company Employee FORMCHECKBOX Agent FORMCHECKBOX Other (specify) FORMTEXT       FORMTEXT      Name of Representative Declining RiskI believed this insurer would consider underwriting this risk because: FORMCHECKBOX Recent acceptance by the insurer of a risk, requiring that type of coverage or class of Insurance. FORMCHECKBOX Advertising by the insurer or its agent indicating it entertains that type of risk/coverage. FORMCHECKBOX Media communications (Newspapers, Trade Magazines, Radio) which indicate the insurer will underwrite that type of coverage. FORMCHECKBOX Communications with other professionals, such as brokers, agents, risk managers, insurancedepartment or ELANY Personnel indicating the insurer entertains such risks. FORMCHECKBOX Any other valid basis you can document. FORMTEXT      NYSID Form 41C - W (Ed. July 2011) Page 1 of 2 PART C  AFFIDAVIT BY PRODUCING BROKERAFFIDAVIT NO.AUTHORIZED COMPANIES DECLINING THE RISK2.Name of Company FORMTEXT      Date Declin.: FORMTEXT      NAIC Code FORMTEXT      The insurer declined to underwrite the risk because:1. FORMCHECKBOX Insurer presently lacks adequate capacity to write this risk.2. FORMCHECKBOX Specific underwriting reason.3. FORMCHECKBOX Other (Specify) FORMTEXT      Affiliation of Representative: FORMCHECKBOX Company Employee FORMCHECKBOX Agent FORMCHECKBOX Other (specify) FORMTEXT       FORMTEXT      Name of Representative Declining RiskI believed this insurer would consider underwriting this risk because: FORMCHECKBOX Recent acceptance by the insurer of a risk, requiring that type of coverage or class of Insurance. FORMCHECKBOX Advertising by the insurer or its agent indicating it entertains that type of risk/coverage. FORMCHECKBOX Media communications (Newspapers, Trade Magazines, Radio) which indicate the insurer will underwrite that type of coverage. 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FORMCHECKBOX Any other valid basis you can document. FORMTEXT      3.Name of Company FORMTEXT      Date Declin.: FORMTEXT      NAIC Code FORMTEXT      The insurer declined to underwrite the risk because:1. FORMCHECKBOX Insurer presently lacks adequate capacity to write this risk.2. FORMCHECKBOX Specific underwriting reason.3. FORMCHECKBOX Other (Specify) FORMTEXT      Affiliation of Representative: FORMCHECKBOX Company Employee FORMCHECKBOX Agent FORMCHECKBOX Other (specify) FORMTEXT       FORMTEXT      Name of Representative Declining RiskI believed this insurer would consider underwriting this risk because: FORMCHECKBOX Recent acceptance by the insurer of a risk, requiring that type of coverage or class of Insurance. FORMCHECKBOX Advertising by the insurer or its agent indicating it entertains that type of risk/coverage. FORMCHECKBOX Media communications (Newspapers, Trade Magazines, Radio) which indicate the insurer will underwrite that type of coverage. 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TZ\xz|wua&jMh B*CJUaJphU&jTLh B*CJUaJph&jJh B*CJUaJph&jIh B*CJUaJphhqB*CJaJph&jSHh B*CJUaJph jhqB*CJUaJphhqB*CJaJphhW$hqB*CJaJph#/pMkdH$$Ifl40h*4)4 laf4$If:kdH$$Ifl4*+4 laf4cJkdJ$$Ifl0h*4)4 la$IfJkd.I$$Ifl0h*4)4 la vwxcJkd7K$$Ifl0h*4)4 la$IfJkdbJ$$Ifl0h*4)4 lacJkdK$$Ifl0h*4)4 la$IfJkdK$$Ifl0h*4)4 laCommunications with other professionals, such as brokers, agents, risk managers, insurancedepartment or ELANY Personnel indicating the insurer entertains such risks. FORMCHECKBOX Any other valid basis you can document. FORMTEXT      AFFIRMATIONI, FORMTEXT      ,am the licensee or sublicensee of the named brokerin Section 1 of this affirmation and I hereby affirm under penalties of perjury that all of theinformation contained herein is true to the best of my knowledge and belief.Signature of Affiant Date FORMTEXT       NYSID Form 41C - W (Ed. 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