18 Del. Admin. Code § 1901-9.0

Current through Register Vol. 28, No. 5, November 1, 2024

Section 1901-9.0 - APPENDIX

CONSENT-TO-RATE FILINGS

Note: The following is a format to be used by agents and brokers requesting approval for "excess" rates. Forms will not be provided by the Delaware Insurance Department.

CONSENT-TO-RATE APPLICATION FORMAT

TO: INSURANCE COMMISSIONER

STATE OF DELAWARE

841 SILVER LAKE BOULEVARD

DOVER, DELAWARE 19904

ATTN.: RATING SECTION

Pursuant to 18 Del.C. § 2509, and in accordance with Regulation 1901 (Formerly Regulation 33), the following information is submitted, seeking approval for the coverage at the rate indicated.

9.1 RISK IDENTIFICATION

9.1.1 Name of Insured/Risk_________________________________________

Address_____________________________________________________

9.1.2 The location of the risk_______________________________________ _____________________________________________________________

9.1.3 The type of insurance (description of coverage to be provided)

_____________________________________________________________

9.1.4 Limits of liability__________________________________________

______________________________________________________________

9.1.5 Dates of coverage: From________________ To________________

9.1.6 Insurer providing coverage___________________________________

9.1.7 Rates:

1. Total manual rate for this risk $_________________

2. Total proposed rate for this risk ' $_________________

9.1.8 For personal lines:Was this risk submitted for consideration by the Delaware automobile Insurance Plan (Assigned Risk)/Delaware FAIR Plan?____________________________________

If not, state reason why not____________________________________

_____________________________________________________________

9.2 PRODUCER'S STATEMENT

9.2.1) Name of Producer____________________________________________

9.2.2 Business Address____________________________________________

9.2.3 Telephone Number___________________________________________

9.2.4 Description of circumstances which cause the risk to be regarded as an other than ordinary risk subject to regular rates as filed.

_____________________________________________________________

(Be specific in this statement. Remarks in the nature of "class of business" or "type of risk" will not be adequate to review the request for an excess rate)

PRODUCER'S CERTIFICATION

Pursuant to Regulation 1901 (Formerly Regulation 33), I certify that I have informed the applicant/risk to be insured of the circumstances regarding the risk, and, further, that I have informed the insured of the excess rate and of the premium to be applied, as reflected above, by________________________, for

(Name of Insurer)

covering the risk.

Date:_________________ ____________________________________

Signature

____________________________________

(Typed or Printed Name)

9.3 Insured's Statement

I have been advised of and understand the contents of this application for a consent-to-rate in excess of the rate otherwise applicable. I request that the proposed rate and resulting premium be approved, pursuant to 18 Del.C. § 2509.

Date:_________________ ____________________________________

Signature

____________________________________

(Typed or Printed Name)

Date:_________________ ____________________________________

Witness Signature

____________________________________

(Typed or Printed Name)

18 Del. Admin. Code § 1901-9.0