Statement of Diligent Effort - Florida Form

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)

First Authorized Insurer

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)

What is the person’s phone number?

What is the person’s email?

What was the date of contact?

Why did the insurance company decline the risk? (Attach electronic declinations, if applicable)

Insurer presently lacks adequate capacity to write this risk
Specific underwriting reason
Other

Please enter the reason the insurance company declined the risk.

Second Authorized Insurer

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)

What is the person’s phone number?

What is the person’s email?

What was the date of contact?

Why did the insurance company decline the risk? (Attach electronic declinations, if applicable)

Insurer presently lacks adequate capacity to write this risk
Specific underwriting reason
Other

Please enter the reason the insurance company declined the risk.

Third Authorized Insurer

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)

What is the person’s phone number?

What is the person’s email?

What was the date of contact?

Why did the insurance company decline the risk? (Attach electronic declinations, if applicable)

Insurer presently lacks adequate capacity to write this risk
Specific underwriting reason
Other

Please enter the reason the insurance company declined the risk.

Retail/Producing Agent Signature

Place the signature of the retail/producing agent in the box below.

Enter the date this form is being signed.

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Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.

Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes. *

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Statement of Diligent Effort - Florida Form

First Authorized Insurer

Second Authorized Insurer

Third Authorized Insurer

Retail/Producing Agent Signature

Alice Romeo

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Statement of Diligent Effort - Florida Form

First Authorized Insurer

Second Authorized Insurer

Third Authorized Insurer

Retail/Producing Agent Signature

Alice Romeo

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