N.M. Admin. Code § 13.19.2.19 - PRODUCING BROKER AFFIDAVIT

This affidavit shall be completed by the producing broker (e.g., the agent selling the product) and submitted to the surplus lines broker within fifteen days of issuance of the policy.

PRODUCING BROKER AFFIDAVIT

(Required by 59A-14-11B NMSA 1978 Section)

Name of producing broker: ____________________________________

Address of producing broker: _________________________________________

Being duly sworn, I affirm that:

1. I was engaged to obtain the following policy:

Insurer: _______________________

Policy number: ________________________

Type of coverage: _______________________

Effective date: __________________________

2. (Check either A or B below, as appropriate)

A. After making a diligent search I found that the full amount or type of insurance requested could not be obtained from authorized insurers in New Mexico.

or

B. Within the last year, I have tried to place this type of coverage with at least four insurers authorized in New Mexico, including insurers by whom I am not appointed, and therefore know from substantial recent experience that this coverage cannot be obtained from any authorized insurer in New Mexico.

3. I expressly advised the insured prior to placing the insurance, and the insurance policy states, that:

A. the insurer with whom the insurance is placed is not an authorized insurer in New Mexico and is not subject to the supervision of the superintendent of insurance; and

B. in the event the insurer becomes insolvent, claims will not be paid by any New Mexico guaranty association.

4. I have asked the insured and, to the best of my knowledge, this coverage is not replacing existing coverage from an authorized insurer who was willing to continue providing coverage.

5. I certify that I am licensed by the New Mexico department of insurance for the type of coverage provided and that the information in this form is true and correct and is in compliance with the applicable provisions of the New Mexico insurance code and this rule.

_________________________________ _______________________

SIGNATURE DATE

SUBSCRIBED AND SWORN TO before me

this ____ day of _____________, ____.

_______________________________________________

Notary Public

My commission expires ______________

Notes

N.M. Admin. Code § 13.19.2.19

1/1/99; Recompiled 11/30/01