Forms

I have determined that, as per the definition as stated in the federal Nonadmitted and Reinsurance Reform Act of 2010 Sec. 527, Oregon is the “home state” for this policy. (A copy of the federal Nonadmitted and Reinsurance Reform Act of 2010 can be viewed online at www.OregonSLA.org under “Publications”).

A. The Surplus Lines insurer with whom the insurance was placed is not licensed in this state and is not subject to its supervision.

B. In the event of the insolvency of the SURPLUS LINES insurer, losses will not be paid by the STATE INSURANCE GUARANTY FUND.

Select (check) Statement 1, Statement 2, OR Statement 3:

I hereby certify that I have made a diligent effort to place this insurance with companies admitted to write business in Oregon for this class. I am unable to place the full amount or kind of insurance with companies admitted to transact and who are actually writing the particular kind and class of insurance in this state. I am therefore placing this insurance in the SURPLUS LINE MARKET.

I have determined that the insured is currently registered with Oregon as a Risk Purchasing Group (RPG), to purchase liability insurance on a group basis, and that this policy placement is exempt from the Diligent Search requirement.

I have determined that, as per the definition as stated in the Nonadmitted and Reinsurance Reform Act of 2010 Sec. 527, this insured is an exempt commercial purchaser, that the requirements as set forth in the federal Nonadmitted and Reinsurance Reform Act of 2010 Sec. 525 have been complied with, and that this policy placement is exempt from the Diligent Search requirement. (A copy of the federal Nonadmitted and Reinsurance Reform Act of 2010 can be viewed online at www.OregonSLA.org under “Publications”).