Free Louisiana Authorized Non-Admitted Affidavit Form - PDF Form Download
Louisiana Revised Statutes R.S. 22 § 1249 et. Seq. mandates filing form 1263.1 Authorized Non-Admitted Affidavit or Louisiana Authorized Non Admitted Affidavit form when you as a licensed Louisiana casualty and property broker or agent procure insurance coverage from surplus line company.
You must secure coverage with admitted authorized company. Please understand that the Louisiana Department of Insurance does not regulate surplus line company. In addition, Louisiana Insurance Guaranty Association is not responsible for payment towards losses and/or claims in the event such surplus line company declares insolvency. You must date and sign the Insured’s Attestation in form 1263.1 to acknowledge the same. Please enclose duly completed Authorized Non Admitted Affidavit Form along with your application before submitting it to licensed Louisiana surplus line broker.
- You may procure insurance coverage from approved unauthorized insurers also designated as surplus lines companies in the event when authorized insurers are unable to provide the same under the provision in Louisiana Revised Statutes 22§1249 et. Seq. and L.R.S. 22§1257.
- Please read Louisiana Authorized Non Admitted Affidavit Form 1263.1 carefully to understand the provisions and requirements from you.
- You must date and sign the Insured’s Attestation in acceptance of the terms and condition mentioned.
- You are not permitted to alter the language and/or format of the Louisiana Authorized Non Admitted Affidavit Form 1263.1 in whatsoever manner.
- Please keep a copy of the duly completed form with you for future reference.
Steps to Prepare Louisiana Authorized Non Admitted Affidavit Form 1263.1
- Enter the name of the Approved Unauthorized Insurer from whom you are procuring the coverage on the first line of Louisiana Authorized Non Admitted Affidavit Form 1263.1.
- Please select your response by marking the box for the next three lines. In addition, you must specify the reason for seeking coverage from the aforementioned approved unauthorized insurer after selecting the third box from this section.
- Enter name of Louisiana Surplus Lines Producer on the next line.
- Enter Louisiana License Number of the Surplus Lines Producer on the following line.
- Enter Policy and/or Binder number when available.
- Enter your name as Property & Casualty Producer on the subsequent line. Then provide your address, name of the city, name of the state, and zip code in the respective spaces.
- Complete this portion of Louisiana Authorized Non Admitted Affidavit Form 1263.1 or Authorized Non-Admitted Affidavit by entering the date, signature, and your phone number with area code.
- Read Insured’s Attestation carefully, enter your printed name and date, and sign in the space provided for the same. You disregard the Louisiana Insurance Guaranty Association from any payment liability towards the losses or claims in case the unauthorized insurer declares insolvency.