Southern Risk Specialists, Inc

BROKER RESPONSIBLE FOR SURPLUS LINES FILING AGREEMENT

Insured Name:

Insured Address:

Policy Number:

Effective Date:

Gross Premium:

This policy is written on a surplus lines basis by (please check the appropriate box):

AIG Specialty Insurance Company

Lexington Insurance Company

Other:

Please return a copy of this Agreement to:
Underwriter:

It is agreed that the following surplus lines agent/broker is responsible for all surplus lines filing, reporting, tax and fee collection and payment requirements imposed by applicable law in the insured’s home state(see attached definition) of

with respect to the policy referenced above.

Firm Name:

Firm Address:

HomeStateSurplus Lines License Number:

A copy of the surplus lines license number referenced above as well as any documentation supporting the payment of surplus lines taxes and applicable fees hereunder will be made available upon request.

CALIFORNIA HOME STATE RISKS: Pursuant to subdivision (b) of Section 1774 of the California Insurance Code, a copy of this Agreement shall be made available to the California Commissioner of Insurance or his or her designee upon request.It is agreed that the responsibility for filing the Confidential Report of Surplus Lines Placement (SL-1 Form) is delegated to the abovementioned surplus lines broker.

TEXAS HOME STATE RISKS: Pursuant to Section 981.223(a) of the Texas Insurance Code, a copy of this Agreement shall be made available for inspection by the Department of Insurance and the Comptroller of Public Accounts. It is agreed that the responsibility for all filing, reporting, collection and payment requirements imposed by Chapter 225 and by Chapter 981 of the Texas Insurance Code is delegated to the abovementioned surplus lines agent. The agency checked below is exercising underwriting authority for Texas Home state risks on behalf of the surplus lines insurer indicated above pursuant to a written agreement that satisfies the requirements of 28 TAC §15.6(e).

Risk Specialists Companies Insurance Agency, Inc.Surplus Lines Agent/Broker responsible for the filing identified above*

AIG Property Casualty Insurance Agency, Inc.

By**:By***:

Date (MM/DD/YY) Signature

**Required for Texas and California Only

***This form must be signed for all states. CA/TX: Requires the individual surplus lines license number and signature of the licensed agent/broker.

DEFINITIONS

HOMESTATE –

(A)In general. – Except as provided in subparagraph (B), the term “home state” means, with respect to an insured –

(i)the state in which an insured maintains its principal place of business or, in the case of an individual, the individual’s principal residence; or

(ii)if 100 percent of the insured risk is located out of the state referred to in clause (i), the state to which the greatest percentage of the insured’s taxable premium for that insurance contract is allocated.

(B)Affiliated Groups. – If more than 1 insured from an affiliated group are named insureds on a single non-admitted insurance contract, the term “home State” means the home State, as determined pursuant to subparagraph (A), of the member of the affiliated group that has the largest percentage of premium attributed to it under such insurance contract.

Affiliate – The term “affiliate” means, with respect to an Insured, any entity that controls, is controlled by, or is under common control with the Insured.

Affiliated Group – The term “affiliated group” means any group of entities that are all affiliated.

CONTROL – An entity has “control” over another entity if –

(A)the entity directly or indirectly or acting through 1 or more other persons owns, controls or has the power to vote 25 percent or more of any class of voting securities of the other entity; or

(B)the entity controls in any manner the election of a majority of the directors or trustees of the other entity.

PRINCIPAL PLACE OF BUSINESS – The term “principal place of business” means, with respect to determining the home state of the Insured:

(A)the state in which an Insured maintains its headquarters and the Insured’s high level officers direct, control and coordinate the business activities; or

(B)if the Insured is a company which maintains outside any state its headquarters where the Insured’s high level officers direct, control and coordinate the business activities, (for example a foreign company headquartered in a foreign country), then the state where the largest percentage of the risk resides, i.e. the state to which the greatest percentage of the Insured’s taxable premium for the insurance contract is allocated.

PRINCIPAL RESIDENCE– “Principal residence” means, with respect to determining the Home State of the insured, (a) the state where the insured resides for the greatest number of days during a calendar year; or (b) if the insured’s principal residence is located outside any state, the state to which the greatest percentage of the insured’s taxable premium for that insurance contract is allocated.

STATE – The term “state” includes any state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, the Northern Mariana Islands, the U.S. Virgin Islands, and American Samoa.