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SL-1 Form

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:


1.
hereby submits that he/she is:
(A) a duly licensed surplus line broker, license number
; or,
(B) a transactor on the surplus line license of
,
(C)
: and, that he/she or said organizational licensee was engaged by the insured, or the insured's broker, named herein, to obtain insurance against certain risk as descrived in this report.
2.
Risk Description
(A) Name of Insured
(B) Address of Insured
(C) Description of the Risk
(D) Location of Risk
(E) Export List code or Coverage Code
3.
Placement Description

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.