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Or surplus lines broker depending upon the filer type. Insurance Company (Direct Writer): Surplus Lines Broker: Name Name Address Address City, State, ZIP Phone City, State, ZIP Email Address Phone Account Number Email Address Employer Identification Number For the Quarter Ending NAIC Number Name of City, County, or Urban County Government: LOUISVILLE METRO, KENTUCKY IF NO PREMIUMS WERE RECEIVED, WRITE NONE ON FORM, SIGN, AND RETURN. (1) (2) (.

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