Confidential Report of Surplus Line Placement
Please refer to the Instructions page and the California Export List for assistance in completing this form.
Please check ONE box only:
(C) Description of the Risk
(E) Export List code or Coverage Code
List Nonadmitted Insurer(s) Underwriting This Policy with % of Premium. (Include an attachment if additional space is needed, or attach a line slip.) If Gap provision applies, please include GAP Form Attachment.