NEW MEXICO SURPLUS LINES BROKER’S COUNTERSIGNATURE ENDORSEMENT

THIS ENDORSEMENT MUST BE ATTACHED TO THE POLICY

AS PART OF THE INSURANCE CONTRACT

This policy provides surplus lines insurance by an insurer not otherwise authorized to transact business in New Mexico. This policy is not subject to supervision, review or approval by the superintendent of insurance. The insurance so provided is not within the protection of any guaranty fund law of New Mexico designed to protect the public in the event of the insurer’s insolvency.

POLICY NUMBER: ______________________________________________________________

NAME OF INSURED: ____________________________________________________________

CERTIFICATE NUMBER: _________________________________________________________

DATE POLICY SIGNED: __________________________________________________________

UNDERWRITING COMPANY: _____________________________________________________

_______________________________

Surplus Lines Brokers Signature

[1/1/99; Recompiled 11/30/01]

HISTORY OF 13.19.2 NMAC:

Pre-NMAC History: The material in this rule was originally filed with the State Records Center as part of ID 67-1, New Mexico Official Administrative Rules and Regulations Code, on December 1, 1967.

History of Repealed Material:

13 NMAC 19.2, Writing Surplus Line Business, was repealed effective 12-31-98 and was repromulgated as 13 NMAC 19.2, Writing Surplus Line Business, effective 1/1/99.