L E awrence xcess

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)