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Washington State Office of the Insurance Commissioner

Compensation disclosure - form and instructions

In response to your requests and responses to our survey, we've developed a compensation disclosure form to help you keep compliant records.

On this page:

Survey - description and results

In August 2011, 88 licensed individual producers and 89 licensed agencies were randomly selected to participate in a survey regarding compensation disclosure. 

    • We received 123 (70 percent) responses. 
    • Of those 123 responses, only 23 of the licensees charged fees to their clients. 

We reviewed the licensees' disclosure forms and found:

    • All 23 licensees dealt directly with the insured and all 23 used some form of disclosure.
    • 19 (82 percent) of the 23 disclosed the fee being charged.
    • 9 (39 percent) of the 23 disclosed commissions they received in addition to the fee charged.
    • 10 (43 percent) of the 23 disclosed the possibility of contingent commissions.
    • 12 (52 percent) of the 23 disclosed the name of the insurance company paying the commissions.
    • 21 (91 percent) of the 23 had the proper signatures (licensee's and client's) on the disclosure form.
    • Only 7 (30 percent) of the 23 disclosure forms were in compliance with RCW 48.17.270.

In response to the survey results, we've drafted a sample compensation disclosure form that can be used by licensed producers.  It is not a requirement that you use our sample, it's posted for your convenience.

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How to use the form

  • If the only compensation you receive is from the fee being charged (you do not receive any commission), you need only complete Part 1 of the from.
  • If you charge a fee and receive a commission from an insurer, you need to complete Parts 1 and 2 of the form.  If you will offset some or all of the fee, provide an explanation of how the offset works under Part 2.
  • If you charge a fee, receive an initial commission and could possibly receive contingent commissions in the form of awards, bonuses, etc., you need to complete Parts 1, 2 and 3 of the form.
  • Always make sure that both the writing producer and the insured/client sign and date the form.  The completed form should be retained by the writing producer for five years.
If the only compensation you receive is a commission from an insurer, there is no need to complete a compensation disclosure form.

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Questions?

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Updated 04/27/2012

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