Alabama Diligent Effort Form

Alabama Diligent Effort (Declination) Statement

For Surplus Lines Placements – Ala. Code §27-10-20
Named Insured:
Mailing Address:

Street Address

Street Address Line 2

CityState

Zip Code
Description of Risk
Admitted Carrier Declination
Carrier Name (or NAIC#)
Carrier Name or NAIC # (if not in list above)
Date of Declination

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Declination
Agent Name:
Agency Name:
Agent Email
A copy of your submitted form will be sent to this address
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty:

Alabama Diligent Effort (Declination) Statement