In the event of the entry of a decree ordering liquidation of an insurer, the responsibility of the agent to render premiums to the receiver shall be as follows:
(AFFIDAVIT BY INSURED)
(Name of insured of (street, city or town, state), being duly sworn, deposes and says that on (date), he (she) directed his (her) insurance agent or broker to obtain insurance against certain risks covering property as described on the reverse side; that his (her) insurance agent or broker informed him (her) that (only part of) (no part of) the required insurance could be obtained from companies admitted to transact business in the state of Rhode Island, to wit: ($); and that he (she) informed me that he (she) made a diligent effort to procure the full amount of insurance from admitted insurers, but was unable to do so.
The following companies or groups and officer(s) or agent(s) of these companies or groups are among those which have declined the offering or accepted a part of it:
_________
I was further informed that the amount of insurance shown below could be obtained from certain insurers not admitted to transact business in the state of Rhode Island. I therefore directed ________ a licensed Rhode Island agent (broker) to obtain this insurance from these non-admitted companies through the office of ________ a licensed surplus line broker. This insurance was only the excess over the amounts procurable from admitted insurers. ________ personally appeared before me _______ and made oath that the above affidavit signed by him (her) is true to the best of his (her) knowledge and belief.
________________________
(Signature of Insured)
____________
(Notary Public)
R.I. Gen. Laws § 27-14.4-21