Lawrence Excess
General: (516) 431-9191
Underwriting: (516) 431-6200 • Fax: (516) 431-0488
370 West Park Avenue, P.O. Box 9004
Long Beach, NY 11561-9004
Notice of Surplus Lines Offering
The undersigned applicant has been advised by the undersigned originating insurance
producer and understands that an insurance policy written by a surplus lines insurer is not
subject to the filing or approval requirements of the New Jersey Department of Banking
and Insurance. Such a policy may contain conditions, limitations, exclusions and
different terms than a policy issued by an insurer granted a Certificate of Authority by the
New Jersey Department of Banking and Insurance.
Total Cost Provision
In consideration of your placing my insurance, I agree to pay the total cost below which
includes all premiums, fees and Surplus Lines Tax.
I further understand and agree that 25% of the premium and tax are earned from
inception and all fees are fully earned. Further, any policy changes which generate
additional premium are subject to additional tax.
Policy Premium
$
Surplus Line Tax (3.0%)
$
Policy Fee
$ 50
Inspection Fee
$
Producer Fee
$
Total Cost
$
Applicant’s Signature
Producer Signature
Applicant’s Name (Print or Type)
Producer Name (Print or Type)
Date of Applicant’s Signature
Date of Producer Signature
New Jersey Producer License Reference Number:
LE-NJ-NSL-TCP (05/08)