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
Date
Reason for Declination*
Agent Name:*
Agency Name:*
Agent Email*
A copy of your submitted form will be sent to this address
Signature*

Clear
Date*

MonthDayYear
Should be Empty:

Alabama Diligent Effort (Declination) Statement