Who is the named insured? (The name of the insured must be precisely the same in this affidavit and the declarations page, binder, cover note or confirmation of coverage.)
What is the name of the producing agent/broker?
What is the producing agent/broker’s Florida license number?
What is the name of the agency?
Enter the specific type of coverage the producing agent sought to obtain through authorized insurers. (Ie. Homeowners)
Enter the name of the first authorized insurance company declining the risk.
What is the full name (first and last name) of the person contacted? (Or indicate if an online declination was obtained)
Please enter the reason the insurance company declined the risk.
Enter the name of the second authorized insurance company declining the risk.
What is the full name (first and last name) of the person contacted? (Or indicate if an online declination was obtained)
Please enter the reason the insurance company declined the risk.
Enter the name of the third authorized insurance company declining the risk.
What is the full name (first and last name) of the person contacted? (Or indicate if an online declination was obtained)
Please enter the reason the insurance company declined the risk.