Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the document and open it in your online editor.
2. Enter the transaction number by filling in the appropriate blank fields at the top of the form.
3. In the designated sections, provide the name and address of the insured, including street address, city or town, state, and zip code.
4. Fill in the details of the insurance coverage required. Specify the type of coverage and the location of the property or risk involved.
5. Indicate the policy limits as per the requirements of the insurance that is being procured.
6. Complete the information regarding the surplus lines agent representing the insured, including their name, title, and the name of the business, corporation, or partnership they represent.
7. Fill out the agent's address, including street address, city or town, state, and zip code.
8. List the ineligible unauthorized insurers in the provided fields, ensuring to include the NAIC and ISI numbers where applicable.
9. Confirm the certification statements regarding the ineligible unauthorized insurer’s compliance with the commissioner’s regulations.
10. Sign the form in the designated area to verify the information provided is accurate and complete.
11. Finally, save the changes you made, then download, print, or share the completed form as necessary.

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