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Get DE SL-1923 (Formerly SL-1904) 2012

RT Form SL-1923 SL BROKER Formerly Form SL-1904 DO NOT SUBMIT THIS FORM TO THE INSURANCE DEPARTMENT POLICY NUMBER SURPLUS LINES INSURER NAME INSURED'S NAME AND MAILING ADDRESS: Name: NAIC # POLICY TERM INFORMATION Effective Date Expiration Date MM/DD/YYYY Format MM/DD/YYYY Format Address: AMOUNT OF INSURANCE Casualty Property DESCRIPTION OF COVERAGE: LOCATION OF RISK I declare under the penalties provided by law that I have made a diligent effort to procure the insurance coverage.

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