SURPLUS LINES BROKER AFFIDAVIT
(Please complete all fields)

Name of Licensed Broker:  

South Dakota Surplus Lines Broker License Number  

Name of Contact entering Affidavits:         Phone:  

Email Address of contact person:  

Insurance Company Issuing Policy
 

Company or organization (MGA) procuring coverage for surplus line broker if other than issuing company
 

Insured Name
 

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Address of Insured
City:		State(Abbrv):		Zip Code:

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Address of Insured Property
City:		State(Abbrv):		Zip Code:

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Effective Date:		Term		Types of Coverage
Premium		Fees		Surplus Line Tax

Year Tax Being Paid In (Example 2003 or 2004)  
(4th quarter paid in January 2005 are still 2004 taxes as are taxes paid by due date of April 1as they are for year ending 2004)

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Risk Retention Group or Risk Purchasing Group (Complete this section in addition to the above)

Name of Risk Retention or Risk Purchasing Group  
(If you do not have a Risk Retention or Risk Purchasing Group, Please enter NONE or N/A)

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South Dakota
Division of Insurance
445 East Capitol Avenue
Pierre, South Dakota 57501
Producer Licensing: (605) 773-3513
Continuing Education: (605) 773-3946
http://www.state.sd.us/drr/reg/insurance/

If you have questions concerning the affidavit, please contact us at insurance@state.sd.us.