Laserfiche WebLink
PRODUCER SURPLUS LINES CERTIFICATION <br />IMPORTANT: This agreement must be completed by the broker responsible for the surplus lines tax <br />filings. <br />To ensure compliance with laws and regulations regarding Surplus Lines business, we are furnishing you <br />with the name, address and license number for the Surplus Lines broker who will arrange for affidavit <br />filings, payment of applicable taxes and fees, and compliance with any other requirements, with respect <br />to the above -referenced policy. <br />SURPLUS LINES BROKER INFORMATION <br />INSURED INFORMATION <br />INSURED NAME: <br />Nunez Construction Inc <br />INSURED CITY/STATE: <br />South Miami, FL <br />POLICY NUMBER: <br />LICENSE NUMBER: <br />POLICY EFFECTIVE DATE: <br />8/15/2024 <br />WRITING COMPANY: <br />Benchmark Specialty Insurance Company <br />PRODUCER NAME: <br />Bass Underwriters <br />PRODUCER CITY/STATE: <br />St Petersburg, FL <br />To ensure compliance with laws and regulations regarding Surplus Lines business, we are furnishing you <br />with the name, address and license number for the Surplus Lines broker who will arrange for affidavit <br />filings, payment of applicable taxes and fees, and compliance with any other requirements, with respect <br />to the above -referenced policy. <br />SURPLUS LINES BROKER INFORMATION <br />LICENSED SURPLUS LINES <br />DATE: <br />BROKER NAME: <br />BROKER'S <br />SURPLUS LINES BROKER <br />LICENSE NUMBER: <br />SIGNATURE: <br />NPN NUMBER: <br />(National Producer Number <br />SURPLUS LINES BROKER <br />ADDRESS: <br />NEW JERSEY TRANSACTION <br />NUMBER: <br />(New Jersey Domiciled Risks Only) <br />LICENSED <br />DATE: <br />BROKER'S <br />SIGNATURE: <br />Please return this completed form. <br />BEAT-SLNOTICE 03/2022 <br />