DILIGENT SEARCH REPORT

Question #1

Transactor *:

AGENT

Broker and Agent Name:

(A) Duly licensed under California Department of Insurance license number:

OR

AGENCY

(B) Duly licensed and authorized to act as an endorsee on the organizational license of:

California Department of Insurance license number:

and (C) that he/she orsaid organizational licensee was engaged by the insured named herein, or the insured's broker, to obtain insurance as described in this report;

and (D) is the licensee who performed or supervised this diligent search.

Question #2

(A) Name of Insured *:

(B) Address of Insured*
Can't be a PO BOX

Street and Number *:

City *:

State *:

Zip Code *:

(D) Location of Risk

Same as above

Various Locations

Street and Number *:

City *:

State *:

Zip Code *:

(E) Type of Insurance coverage

Question #3.

If Private Passenger Automobile Liability Insurance is identified on line 2(E), complete the following:

(A) Does the insured qualify as a "Good Driver" under Section 1861.025 of the California Insurance Code?

Yes No

(B) Does the coverage that you have placed include, in whole or in part, the limits of coverage provided under the California Automobile Assigned Risk Plan (CAARP)?

Yes No

If YES, has this risk been submitted to and found to be ineligible by CAARP?

Yes No

If your answer is NO, then this coverage cannot be placed with a non-admitted insurer. (See Insurance Code section 1763.5)

Question #4.

If Health Insurance is identified on line 2(E), does the insured qualify as a "Small Employer" under Section 10700(x) of the California Insurance Code? *:

Yes No

Question #5.

If this insurance was placed pursuant to Section 125 et seq. of the California Insurance Code governing transactions with risk purchasing groups authorized by the Federal Liability Risk Retention Act of 1986, complete the following

(A) Provide the name and address of the purchasing group of which the insured is a member

Question #6.

(A) Describe the diligent efforts made to place this coverage with admitted insurers and describe how the search was performed (please add additional pages if necessary) *:

(B) If search was performed by someone other than the person named in Question 1, please provide full name of that individual:

Question #7.

(A) Was the risk described in Section 2 submitted by you or by someone under your supervision to at least (3) insurers that are admitted in California and who actually write the type of insurance described in questions 2(C) and 2(E)? *

Yes No

(B) If YES, please complete ALL sections of the following table; if NO, skip to Section 8:

Full Name of Admitted Company *	First & Last Name of Company Representative AND Telephone Number *	Check if Employee (E) or Agent (A) *	Month, Year of Declination *
1 *.	or “Online Declination” Website	E A	Month Year
2 *.	or “Online Declination” Website	E A	Month Year
3 *.	or “Online Declination” Website	E A	Month Year

Question #8.

If 7(A) was answered NO, complete the following:

(A) Did you determine that fewer than 3 admitted insurers actually write the type of insurance described on lines 2(C) and 2(E)?

Yes No

(B) If NO, please explain in detail why the risk was submitted to less than three admitted insurers in California that write this type of insurance.

The undesigned licensee hereby certifies that this report is true and correct, and that this risk is not being placed with a nonadmitted insurer for the sole purpose of securing a rate or premium lower than the lowest rate or premium available from an admitted insurer.

Signature of Person Named on Line 1:

Date of Signature:

By signing this form and providing a signature date, I agree that all the information contained herein is accurate to the best of my knowledge.