How to Complete the Florida Surplus Lines Disclosure and Acknowledgement Form

The Florida surplus lines disclosure form is a one-page acknowledgment the policyholder signs before coverage is placed with a non-admitted insurer, meaning a carrier not licensed by the Florida Office of Insurance Regulation. The retail or producing agent handling the sale is the one responsible for presenting the form and collecting the insured’s signature or documented acknowledgment.¹ A fillable version is available for download from the Florida Surplus Lines Service Office (FSLSO).²

Who Signs It and Who Is Responsible

The retail or producing agent, meaning the agent who deals directly with the consumer, bears sole responsibility for obtaining and keeping the signed disclosure. It is not the surplus lines agent’s job unless the same person is acting in both roles on the transaction.¹ Many placements involve a chain: the consumer works with a retail agent, who in turn works with a separately licensed surplus lines agent to access the non-admitted market. The retail agent is the one who must get the form in front of you.

Your part is simple. Read the disclosure, understand that no state guaranty fund backs the policy, and sign. Florida law lets the acknowledgment be something other than a wet signature. The statute requires that the insured have “signed or otherwise provided documented acknowledgment,”³ so a properly documented electronic acknowledgment can satisfy the requirement.

When the Form Is Required

The disclosure is a prerequisite for sending a risk to the surplus lines market under Section 626.916. Before an agent can place coverage with a non-admitted carrier, a diligent effort to find coverage among admitted Florida insurers must have failed to produce adequate coverage. Declinations from admitted carriers have to be documented risk by risk, and the surplus lines agent is required to verify the producing agent’s diligent effort through a properly documented statement.³ The statute does not fix a minimum number of declinations; the effort itself just has to be real and documented.

Florida’s Statement of Diligent Effort form, also from the FSLSO, is the standard way agents record those declinations, and it requires any electronic declinations to be attached. The signed disclosure is a separate document from the diligent effort statement, but both must be in place before the placement moves forward. If the producing agent obtains the insured’s physical signature on the disclosure, the insured is legally presumed to have been informed that admitted-market coverage may be available.³

How to Fill Out the Form

The FSLSO’s standard disclosure is a short PDF with only a handful of fields.² Complete it this way:

Name of the surplus lines carrier. Enter the full legal name of the non-admitted insurer providing coverage. The field is labeled “Name of Excess and Surplus Lines Carrier.” Use the exact legal entity name, not a trade name or abbreviation, so it matches the policy declarations page.⁴
Named insured. The full legal name of the person or entity purchasing the policy.
Disclosure language. The body of the form carries the state-mandated acknowledgment text. On the FSLSO’s standard form this language is pre-printed. An agent using a custom form has to include wording “in substantially the following form” as prescribed by Section 626.916(1)(d).³
Insured’s signature, printed name, title, and date. The insured, or an authorized representative of an insured entity, signs, prints their name and title, and dates the form.

Everything on the disclosure should match the declarations page. Even a slightly different entity name can create problems in a regulatory audit. If the insured is a business, the signer should be someone with authority to bind the entity, and the title they print should reflect that authority.

What You Are Acknowledging When You Sign

The acknowledgment covers four points:²

Coverage is being placed in the surplus lines market, meaning with a carrier not licensed by the Florida Office of Insurance Regulation.
Coverage may be available in the admitted market. The form does not say admitted coverage is unavailable, only that the diligent effort process did not produce an adequate policy from a licensed carrier.
No guaranty fund protection. Surplus lines insurers are not members of the Florida Insurance Guaranty Association (FIGA), so FIGA will not pay claims if the carrier becomes insolvent.⁵
Rates and forms are not state-approved. Surplus lines carriers do not submit their policy rates or forms to any Florida regulatory agency for approval.

The no-guaranty-fund warning is the point most worth pausing on. If an admitted insurer fails, FIGA steps in to pay covered claims. If a surplus lines carrier fails, policyholders are effectively unsecured creditors in whatever liquidation follows. The NAIC reports that surplus lines insolvencies have been historically rare,⁶ but the exposure is real and that is what your signature is confirming you understand.

Taxes and Fees You Will See on the Invoice

Surplus lines policies in Florida carry a premium tax of 4.94 percent of gross premiums plus a 0.06 percent service fee.⁷ In the admitted market, premium taxes are generally built into the carrier’s pricing and invisible to the consumer. Here they are disclosed separately. Section 626.916 requires that per-policy fees be “itemized separately to the customer before purchase and enumerated in the policy.”³

On a $10,000 annual premium, the combined 5 percent adds $500. You pay those amounts to the surplus lines agent, who remits them to the FSLSO. They should appear as distinct line items on your invoice. If they don’t, ask your agent to break them out before you sign.

How Long the Signed Form Must Be Kept

The signed disclosure must be retained for five years after the expiration or cancellation of the policy, not five years from the date of signing. Section 626.930 requires surplus lines agents to keep a full and true record of each contract, including applications, certificates, cover notes, and related documents, for that entire period.⁸ On a three-year policy that renews twice, the retention clock does not start until the final policy period ends.

Those records have to be available for inspection at any time, without advance notice, by the Florida Department of Financial Services or the FSLSO.⁸ Originals or high-quality electronic copies are acceptable, but the files have to sit at the agent’s Florida office, or the agent’s state of residence for nonresidents without a Florida office.

The penalties for getting this wrong are not small. Under Section 626.936, a surplus lines agent who fails to file a required report or affidavit can be fined up to $50 per day for each day the failure continues. An agent who fails to pay surplus lines taxes or service fees faces fines of up to $500 per day, plus 9 percent annual interest on the delinquent amount.⁹ Broader enforcement actions, including license suspension, are available under Florida’s unfair insurance practices statutes for agents who repeatedly fall short.

1
Florida Surplus Lines Service Office. When Does the Surplus Lines Agent Keep a Copy of the Disclosure Form?
2
Florida Surplus Lines Service Office. Surplus Lines Disclosure
3
The Florida Legislature. Florida Code 626.916 – Eligibility for Export
4
Florida Surplus Lines Service Office. Florida Surplus Lines Disclosure Form
5
Florida Insurance Guaranty Association. Florida Insurance Guaranty Association
6
National Association of Insurance Commissioners. Surplus Lines
7
The Florida Legislature. Florida Code 626.932 – Surplus Lines Premium Tax
8
Florida Senate. Florida Code 626.930 – Records of Surplus Lines Agent
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The Florida Legislature. Florida Code 626.936 – Penalty for Failure to File Report or Pay Tax