Form FIS2260 "Application for Verifying Eligibility as Surplus Lines Insurer in the State of Michigan" - Michigan

What Is Form FIS2260?

This is a legal form that was released by the Michigan Department of Insurance and Financial Services - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2015;
  • The latest edition provided by the Michigan Department of Insurance and Financial Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form FIS2260 by clicking the link below or browse more documents and templates provided by the Michigan Department of Insurance and Financial Services.

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Download Form FIS2260 "Application for Verifying Eligibility as Surplus Lines Insurer in the State of Michigan" - Michigan

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FIS 2260 (06/15) Department of Insurance and Financial Services (Page 1 of 4)
Application for Verifying Eligibility as
Surplus Lines Insurer in the State of Michigan
________________________________________________________________________
Instructions
This information will assist in complying with the requirements and procedures to become an
eligible surplus lines insurer in Michigan. Please review the following requirements set forth.
1. All documents required with this application must be dated within six (6) months of
submission of the application.
2. A contact person must be designated on the application.
3. It is the responsibility of the applicant to ensure that none of the responses or
submissions in association with this application conflict with the information filed with the
domiciliary state.
4. Using page 3 of this application, detail the types of business and products which the
company intends to write in Michigan on a surplus lines basis and include a copy of the
company’s Certificate of Authority from its state of domicile which verifies the authorized
lines of business.
5. An application fee of $500 must be included with the application and made payable to the
State of Michigan.
6. Alien Applicants Only - Confirmation that the company has been placed on the Quarterly
Listing of Alien Insurers maintained by the International Insurers Department of the
National Association of Insurance Commissioners.
7. All communication should be directed to:
Linda Martin, Application Coordinator
Office of Insurance Evaluation
Department of Insurance and Financial Services
Direct: 517-284-8756
Email:
martinl@michigan.gov
Overnight delivery:
Stevens T. Mason Building
530 W. Allegan Street, 7th Floor
Lansing, MI 48933
First-class mail delivery
P. O. Box 30220
Lansing, MI 48909
PA 218 of 1956 as amended requires submission of this form by companies requesting to become eligible surplus lines
insurers in Michigan.
FIS 2260 (06/15) Department of Insurance and Financial Services (Page 1 of 4)
Application for Verifying Eligibility as
Surplus Lines Insurer in the State of Michigan
________________________________________________________________________
Instructions
This information will assist in complying with the requirements and procedures to become an
eligible surplus lines insurer in Michigan. Please review the following requirements set forth.
1. All documents required with this application must be dated within six (6) months of
submission of the application.
2. A contact person must be designated on the application.
3. It is the responsibility of the applicant to ensure that none of the responses or
submissions in association with this application conflict with the information filed with the
domiciliary state.
4. Using page 3 of this application, detail the types of business and products which the
company intends to write in Michigan on a surplus lines basis and include a copy of the
company’s Certificate of Authority from its state of domicile which verifies the authorized
lines of business.
5. An application fee of $500 must be included with the application and made payable to the
State of Michigan.
6. Alien Applicants Only - Confirmation that the company has been placed on the Quarterly
Listing of Alien Insurers maintained by the International Insurers Department of the
National Association of Insurance Commissioners.
7. All communication should be directed to:
Linda Martin, Application Coordinator
Office of Insurance Evaluation
Department of Insurance and Financial Services
Direct: 517-284-8756
Email:
martinl@michigan.gov
Overnight delivery:
Stevens T. Mason Building
530 W. Allegan Street, 7th Floor
Lansing, MI 48933
First-class mail delivery
P. O. Box 30220
Lansing, MI 48909
PA 218 of 1956 as amended requires submission of this form by companies requesting to become eligible surplus lines
insurers in Michigan.
FIS 2260 (06/15) Department of Insurance and Financial Services (Page 2 of 4)
Application for Verifying Eligibility as
Surplus Lines Insurer in the State of Michigan
_____________________________________________________________________
General Information
Company Name: _____________________________________________________________
Company’s Statutory Home Office Address:
___________________________________________________________________________
___________________________________________________________________________
NAIC # __________________________
FEIN # __________________________
Application Contact Name: _____________________________________________________
Contact Title: ________________________________________________________________
Contact Phone Number: _______________________________________________________
Contact Facsimile Number: ____________________________________________________
Contact Email Address: ________________________________________________________
Contact Mailing Address: _______________________________________________________
FIS 2260 (06/15) Department of Insurance and Financial Services (Page 3 of 4)
Application for Verifying Eligibility as
Surplus Lines Insurer in the State of Michigan
________________________________________________________________________
Current lines of insurance
Lines of insurance authorized on
determined by the Michigan
Certificate of Authority in company’s
Insurance Director to be generally
state of domicile.
(Indicate specific authority
listed on current Certificate of Authority. Please
unavailable in the authorized market
include a copy.)
Animal mortality
Environmental impairment
Kidnap and ransom or extortion insurance
Liability for entertainment, recreational or
sporting events or facilities written to include
injury to participants
Personal injury and/or assault and battery
when not written with bodily injury and property
damage liability
Products recall insurance
Property and liability insurance on mobile,
traveling, or fixed recreational or amusement
businesses
Property insurance on vacant buildings not
insurable through the Michigan Basic Property
Insurance Association
Rain and pluvious insurance
Products liability when written alone
Railroad liability
Flood insurance not provided under the federal
flood insurance program
High hazard cargo insurance
Other – list lines of business and types of
products to be written. Attach a detailed
explanation of the process the applicant will
use to ensure business written on a surplus
lines basis complies with the requirements of
Chapter 19 of the Michigan Insurance Code.
FIS 2260 (06/15) Department of Insurance and Financial Services (Page 4 of 4)
Application for Verifying Eligibility as
Surplus Lines Insurer in the State of Michigan
________________________________________________________________________
Certification for Foreign Surplus Lines Insurer
I hereby certify that
____________________________________________________________________________
Name of Insurance Company -
City and State
currently possesses a minimum capital and surplus of at least $15,000,000 and is currently
licensed in its domiciliary state to write the line or lines of insurance which the applicant will be
writing in Michigan with no restrictions or limitations on the Certificate of Authority of the company
in its domiciliary state.
I further acknowledge that the Company will only write coverage for those lines of insurance that
the Michigan Insurance Director has determined to be generally unavailable in the authorized
market and/or that the Company has appropriate policies and procedures in place to comply with
the requirements of Chapter 19 of the Michigan Insurance Code for other lines of insurance.
___________________________
______________________________________
Date
Signature of Applicant Officer
______________________________________
Printed Name and Title of Applicant Officer
Page of 4