Surplus Lines Broker Quarterly Summary Report Form

SURPLUS LINES BROKER QUARTERLY SUMMARY REPORT (Required by NMSA 1978 Section 59A-14-11C & D) Name of broker: __________________________________ Address of broker: __________________________________ License number: __________________________________ I hereby submit to the New Mexico Department of Insurance this summary of all surplus lines insurance I placed during the quarter beginning ____/____/_____and ending ___/____/______. All documents required by Section 59A-14-11 NMSA 1978 and 13 NMAC 19.2.17.3