FORMS
Surplus Lines Licensee
Affidavits/Declarations
SLL Affidavit (PDF Format) (Word Format) - this form must be
used to submit any of the following four filing types:
1609-SLL/1609-PR - for this filing type, the SLL
Affidavit must be included with the Producer Affidavit 1609-PR as per Section 1609 of the Pennsylvania Surplus Lines
Law
1609-B - for use in reporting a
placement which has been placed with an eligible Surplus Lines Carrier for at
least three consecutive years immediately preceding the current filing as
per Section 1609-B of the
Pennsylvania Surplus Lines Law
1610-A - for use with large accounts as
per Section 1610-A of the
Pennsylvania Surplus Lines Law
1610-B - for use with each PA member of
a Risk Retention or Purchasing Group as per Section 1610-B of the Pennsylvania Surplus Lines Law
Producer Affidavit/Declaration
1609-PR (PDF
Format) (Word Format) - this form is
used in reporting the Declining Companies and must be included with
filing type 1609-SLL/1609-PR as per Section 1609 of the Pennsylvania Surplus Lines Law
Filing Attachments
1606-A (PDF
Format) (Word Format) - to be used for
non-admitted carriers not on the eligible list and is an attachment to the
appropriate Surplus Lines declaration (affidavit) as per Section 1606 of the Pennsylvania
Surplus Lines Law
1609/1610-SH (PDF Format) (Word Format) - for use with Multiple
Carrier placements reported under the same Policy Number, and is an
attachment to the appropriate Surplus Lines declaration (affidavit)
Reporting Forms
1604-E (PDF
Format) (Word Format) - for use in
reporting export filings (in conjunction with a copy of the Declarations
page, binder, or Filing Copy of the Policy.
1620
Report (PDF Format) (Excel Format) - for use in reporting all
surplus lines insurance transacted during the preceding month as per Section 1620 of the Pennsylvania
Surplus Lines Law
RCT-123
Annual Tax Form - This form is issued by the Pennsylvania Department of Revenue and is
in PDF format, which requires Adobe Acrobat Reader to download. The completed
form and payment must be sent to the Pennsylvania Department of Revenue. A
complete copy of this form must also be sent to PSLA.
Binder/Policy
Update Form
(PDF Format) (Word Format) - When submitting a
filing using a Binder number you must
provide PSLA with the Policy number replacing that Binder
number once it becomes available. Licensees should do this using this form.
Surplus
Lines Licensee and Support Staff Information
This form is to be used to update any and all licensee or agency
information changes enabling PSLA to keep proper contact with the licensees
on all matters pertaining to the requirements of the Surplus Lines Law and
its supporting regulations.
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