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Department of Business Regulation
233 Richmond Street
Providence, RI 02903
Affidavit by Broker and Insured Form
AFFIDAVIT BY BROKER
I ___________________________________________________________ swear under penalty
of perjury as follows. I am a Surplus Line Broker licensed pursuant to R.I. Gen. Laws §§ 27-3-1 et
seq. with an office at:______________________________________________________________
(street) (city or town) (state) (zip code)
The following information is true and correct and made in conjunction with my responsibilities as a
licensed Surplus Line Broker.
On _________________________, 2____, as a licensed Surplus Lines Broker, I was engaged by
the insured named herein, either directly or by a licensed Rhode Island producer, to obtain insurance
against the risk(s) described below. Said insured or his(her) producer was unable to obtain the
required insurance with insurers licensed to transact business in the State of Rhode Island. A
diligent effort has been made on behalf of the insured to procure the insurance from insurers licensed
to insure these risks in the State of Rhode Island. The following insurers, licensed to write the type
of insurance which is the subject of this affidavit within the State of Rhode Island, have declined the
coverage referenced above (please note that the name of the officer of the insurer or the producer
that declined risk must be identified):
Insurer Name of Officer or Producer that Declined Risk
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