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					                  A                        B                   C                 D               E               F                G               H                 I                     J                K            L         M            N           O             P            Q          R          S          T          U        V       W
1                                                    QUARTERLY SURPLUS                                                    LINES PREMIUM TAX REPORT
2
3 Risks Placed during (quarter ending) _________________ of 20 ____.
                                              June 30,      2009
4 Surplus Lines Producer Name _____________________________________________
                                         Michael Smirh
5 NPN #                          123456                                                                                                                                                                              License #                         License #                                     License #                                     License #
6                                                                                                                                                                                                                    12345666                          12345666                                      2654888                                       65287168
7                                                                                                                                                              Business placed with:                                Grand Total                        Alabama                                        Alaska                                        Arizona


                                                                                     Type (Line            Written                                                                                                                                             Mult by                Mult
                                     Type (New New Renewal                             # from             Premium                                                                                                                                               Tax                  by Tax Stamp                                Other
        Insured’s Name &              Renewal    Endorsement                 End of   Annual Amount of Collected +                                            Company              Company Name &           %                                    %              Rate   %              Rate   Fee                                  Tax     %
8        Location of Risk           Endorsement)    Date                    Coverage Statement) Insurance Returned -                         Policy #          NAIC #                    Address        Allocated    Premium      Tax        Allocated Premium  6% Allocated Premium 2.7% 1.00%                                  .75% Allocated Premium
     Jim Roe Indianapolis,                                                                                                                                                      Number 1 Liability Co
9    IN                            New                        1/1/2009 12/31/2009                    18.1    1,000,000          25,000           12345           12345          New York, NY                100%       25,000         756     10.00%        2,500         150       25.00%       6,250      169            63      47     45.00%   11,250
     Jerry Roush                                                                                                                                                                Scott Insurance,
10   Noblesville, IN               Endorsement               1/12/2009       7/11/2009               19.3      500,000            3,750           5987           29551          Tallahassee FL              100%        3,750         124     15.00%           563           34     40.00%       1,500       41            15      11     31.00%    1,163
     Goerge Smith 1527 N                                                                                                                                                        Big Bear Insurance
11   21st, St. Nerriille IN        Endorsement               1/14/2009       4/13/2009               17.2        20,000            (990)      3598777            16257          Mystic Falls Mt.            100%         (990)        (28)     0.00%               0          0     50.00%        -495      (13)           (5)     (4)    45.00%     -446
     Aron Lea 2929                                                                                                                                                              Intelligent Space
12   Pendelton Pike,               Renewal                   1/15/2009       1/14/2010                1.0      100,999          21,000        5444444            45957          Insurance Burmingham        100%       21,000         620      5.00%        1,050            63      0.00%            0         0           0         0   75.00%   15,750
     Big Earls Bar 225 N                                                                                                                                                        Love Spring Insurance
13   2nd St. Vincennes, IN         Endorsement               1/20/2009 10/19/2009                    17.1          5,000              500         8976           55678          Masa AZ                     100%            500         24    50.00%           250           15      0.00%            0         0           0         0   20.00%       100
     Luv & Stuff Cartoons,                                                                                                                                                      Industrial Apex
14   Evansville IN                 New                       1/20/2009       1/19/2010                1.0            750        15,000           55555           99568          Insurance Chicago, IL       100%       15,000         501     18.00%        2,700         162       60.00%       9,000      243            90      68     20.00%    3,000
     John Doe 12345 Main                                                                                                                                                        Number 1 Liability Co
15   Street Anytown TX             New                       10/1/2009       9/30/2010           18.1        2,000,000            4,000          54321           12345          New York, NY                100%        3,980         146      1.00%            40            2      1.00%           40         1           0         0   1.00%         40
                                                                                           Same as
16 Same as above                                       Same as above                       above             3,000,000            6,000          54321 AA-12345678 Lloyd's Syndicate #52                    100%        5,970         219      1.00%            60            4      1.00%           60         2           1         0   1.00%         60
                                                                                           Same as
17 Same as above                                       Same as above                       above             3,000,000            6,000          54321 AA-65487989 Lloyd's Syndicate #25                    100%        5,970         219      1.00%            60            4      1.00%           60         2           1         0   1.00%         60

18                                                                                                                                                                                                                            0          0                         0          0                       0         0           0         0                  0

19                                                                                                                                                                                                                            0          0                                    0                                 0           0         0

20 Totals                                                                                                                                                                                                               80,180     2,581                    7,223          433                  16,415       443        164       123              30,977
   Frequency & Due Date                                                                                                                                                                                                                                                Q 3/1,                             Q 3/1,    Q 3/1,
                                                                                                                                                                                                                                                                       5/15,                              5/31,     5/31,
                                                                                                                                                                                                                                                                       8/15,                              8/31,     8/31,
                                                                                                                                                                                                                                                                       11/15                              11/30     11/30
21
22
                                                                                                                                                                                                                                                                                  Payable annually (3/1) unless tax greater than
23                                                          AFFIDAVIT BY SURPLUS LINES BROKER                                                                                                                                                                                     $10,000, then due quarterly
     I, as a licensed Surplus Lines Broker, authorized to transact insurance with the surplus lines insurer(s) named on this Quarterly Surplus Lines Premium Tax Report,
     being duly sworn, depose and declare under the penalties provided under law for filing a false affidavit that a diligent effort has been made to procure said insurance
     coverage from licensed insurers which are authorized to transact the class of insurance involved and which accept in the usual course of business, insurance on risks of
     the same class described herein. Furthermore, this insurance was not placed for the purpose of securing lower rates than would be accepted by any authorized insurer.
     This insurance has been procured with the surplus line insurer(s) named on this Quarterly Surplus Lines Premium Tax Report, which insurance is only the excess over
24   amounts procurable from licensed insurers.
25                                                                                                                                                                              Report prepared by:
26 Surplus Lines Broker Signature: _____________________________________________                                                                                                Name: __________________________________________
27 Printed Name: ______________________________________________________________                                                                                                 Email Address: ____________________________________
28 Dated: ___________________________________________                                                                                                                           Telephone #: _____________________________________


                  16e8709a-febd-42fd-b55f-598fcc306123.xls 11/14/2010
                  A                    X           Y              Z            AA          AB           AC            AD          AE           AF           AG            AH            AI            AJ         AK            AL      AM      AN        AO       AP          AQ        AR           AS       AT      AU         AV        AW         AX
1                                                  QUARTERLY SURPLUS LINES                                                              PREMIUM TAX REPORT
2
3 Risks Placed during (quarter ending) _________________ of 20 ____.
4 Surplus Lines Producer Name _____________________________________________
5 NPN #           License #                         License #               License #                                                                                License #                              License #                           License #                            License #                                            License #
6                 65287168                          98765465                 564654                                                                                  2587416                               4963257239                          324569820                           7598462588                                             82557736
7                  Arizona                          Arkansas                California                                                                               Colorado                              Connecticut                          Delaware                       District of Columbia                                        Florida


                                     Mult                                      Mult                  Mult                                                                 Mult by                   Mult                  Mult                        Mult by              Mult by
                                    by Tax                                    by Tax                by Tax                                   Stamp                         Tax                     by Tax                by Tax Other                  Tax                  Tax    Stamp
        Insured’s Name &             Rate   Stamp                %             Rate   %              Rate                                      Fee          %              Rate       %             Rate   %              Rate   Tax    %              Rate   %             Rate    Fee EMPA
8        Location of Risk            3%    Fee .2%           Allocated Premium 4% Allocated Premium 3%                                       .225%      Allocated Premium  3%     Allocated Premium 4% Allocated Premium 1.75% .25% Allocated Premium  2% Allocated Premium 5%      .1%  Fee
     Jim Roe Indianapolis,
9    IN                                338             23                           0           0                          0           0            0                             0           0                          0        0                 0        0     0                          0           0                0          0       0
     Jerry Roush
10   Noblesville, IN                     35             2                           0           0                          0           0            0                             0           0                          0        0                 0        0     0                          0           0                0          0       0
     Goerge Smith 1527 N
11   21st, St. Nerriille IN             (13)           (1)                          0           0                          0           0            0                             0           0                          0        0                 0        0     0                          0           0                0          0       0
     Aron Lea 2929
12   Pendelton Pike,                   473             32                           0           0                          0           0            0                             0           0                          0        0                 0        0     0                          0           0                0          0       0
     Big Earls Bar 225 N
13   2nd St. Vincennes, IN                 3            0       30.00%           150            6                          0           0            0                             0           0                          0        0                 0        0     0                          0           0                0          0       0
     Luv & Stuff Cartoons,
14   Evansville IN                       90             6                           0           0                          0           0            0                             0           0                          0        0                 0        0     0                          0           0                0          0       0
     John Doe 12345 Main
15   Street Anytown TX                     1            0         2.00%            80           3       3.00%           120            4            0        5.00%              200           6       1.00%           40          2    6.00%     240         4     1          2.00%          80           2   5.00%    200         10         0

16 Same as above                           2            0         2.00%          120            5       3.00%           180            5            0        5.00%              300           9       1.00%           60          2    6.00%     360         6     1          2.00%       120             2   5.00%    300         15         0

17 Same as above                           2            0         2.00%          120            5       3.00%           180            5            0        5.00%              300           9       1.00%           60          2    6.00%     360         6     1          2.00%       120             2   5.00%    300         15         0

18                                         0            0                           0           0                          0           0            0                             0           0                          0        0                 0        0     0                          0           0                0          0       0

19                                         0            0                           0           0                          0           0            0                             0           0                          0        0                 0        0     0                          0           0                0          0       0

20 Totals                   929        62                                         470       19                           480       14       1                                   800           24                    160            6              960        17        2                   320          6              800           40       1
   Frequency & Due Date SA 3/1, M last                                                  M 10th                                 M 1st M last                                           A 3/1                                  Q 2/1,                     A-3/1,                                    SA 2/1,                      Q 1/31, M        M
                        9/1     day                                                                                                   day                                                                                    5/1,                       Q 1/30,                                   8/1                          4/30,    before before
                                                                                                                                                                                                                             8/1,                       4/30,                                                                  7/31,    25th    25th
                                                                                                                                                                                                                             11/1                       7/30,                                                                  10/31
21                                                                                                                                                                                                                                                      10/30
22                                                           Notarized Affidavit                                                                                                                   Notarized Affidavit                                                     Notarized Annual Report
                                                             Payable 60 days after end of
23                                                           AFFIDAVIT BY
                                                             month procured. SURPLUS LINES BROKER
     I, as a licensed Surplus Lines Broker, authorized to transact insurance with the surplus lines insurer(s) named on this Quarterly Surplus Lines Premium Tax Report,
     being duly sworn, depose and declare under the penalties provided under law for filing a false affidavit that a diligent effort has been made to procure said insurance
     coverage from licensed insurers which are authorized to transact the class of insurance involved and which accept in the usual course of business, insurance on risks of
     the same class described herein. Furthermore, this insurance was not placed for the purpose of securing lower rates than would be accepted by any authorized insurer.
     This insurance has been procured with the surplus line insurer(s) named on this Quarterly Surplus Lines Premium Tax Report, which insurance is only the excess over
24   amounts procurable from licensed insurers.
25
26 Surplus Lines Broker Signature: _____________________________________________
27 Printed Name: ______________________________________________________________
28 Dated: ___________________________________________


                  16e8709a-febd-42fd-b55f-598fcc306123.xls 11/14/2010
                  A                     AY              AZ              BA             BB           BC           BD             BE            BF           BG              BH           BI          BJ       BK      BL        BM      BN      BO          BP         BQ           BR      BS       BT          BU        BV         BW         BX
1                                                  QUARTERLY SURPLUS LINES PREMIUM                                                                             TAX REPORT
2
3 Risks Placed during (quarter ending) _________________ of 20 ____.
4 Surplus Lines Producer Name _____________________________________________
5 NPN # License #                                         License #         License #                                                                                     License #                                       License                                License #                      License #                         License #
6        82557736                                        5671335489         4000069                                                                                      792430188                                        65287168                               65287168                           0                                 0
7         Florida                                          Georgia           Hawaii                                                                                         Idaho                                          Illinois                               Indiana                         Iowa                             Kansas


                                                                          Mult by                   Mult by                                                                    Mult by                         Mult         Other                    Mult                Mult                 Mult by
                                                                           Tax                       Tax                                                                        Tax    Stamp                  by Tax Stamp  (Fire                   by Tax              by Tax                 Tax
        Insured’s Name &            Hurricane Citizens      %              Rate       %              Rate     %                                                                 Rate    Fee     %              Rate   Fee Marshal)    %              Rate  %             Rate   %              Rate
8        Location of Risk           Cat Fund Assessment Allocated Premium  4%     Allocated Premium 4.68% Allocated                                                    Premium 1.5%    .25% Allocated Premium 3.5%    .1%  Tax 1% Allocated Premium 2% Allocated Premium 1% Allocated Premium  6%
     Jim Roe Indianapolis,
9    IN                                                                                      0           0                            0            0                             0            0          0                0       0       0         0     20.00%       5,000       100                    0           0                   0           0
     Jerry Roush
10   Noblesville, IN                                                                         0           0                            0            0                             0            0          0   8.00%    300        11       0         3      6.00%         225          5                   0           0                   0           0
     Goerge Smith 1527 N
11   21st, St. Nerriille IN                                                                  0           0                            0            0                             0            0          0                0       0       0         0      5.00%         -50         (1)                  0           0                   0           0
     Aron Lea 2929
12   Pendelton Pike,                                                                         0           0                            0            0                             0            0          0                0       0       0         0     20.00%       4,200        84                    0           0                   0           0
     Big Earls Bar 225 N
13   2nd St. Vincennes, IN                                                                   0           0                            0            0                             0            0          0                0       0       0         0      0.00%             0        0                   0           0                   0           0
     Luv & Stuff Cartoons,
14   Evansville IN                                                                           0           0                            0            0                             0            0          0                0       0       0         0      2.00%         300          6                   0           0                   0           0
     John Doe 12345 Main
15   Street Anytown TX                                                   1.00%             40            2       1.00%               40            2         1.00%              40            1          0   3.00%    120         4       0         1      1.00%           40         1    1.00%         40           0   2.50%         100           6

16 Same as above                                                         1.00%             60            2       1.00%               60            3         1.00%              60            1          0   3.00%    180         6       0         2      1.00%           60         1    1.00%         60           1   2.50%         150           9

17 Same as above                                                         1.00%             60            2       1.00%               60            3         1.00%              60            1          0   3.00%    180         6       0         2      1.00%           60         1    1.00%         60           1   2.50%         150           9

18                                                                                           0           0                            0            0                             0            0          0                0       0       0         0     20.00%             0        0                   0           0                   0           0

19                                                                                           0           0                            0            0                             0            0          0                0       0       0         0     20.00%             0        0                   0           0                   0           0

20 Totals                                                                                  160         6                            160            7                            160           2         0             780         27        1       8                  9,836         197              160             2                 400           24
   Frequency & Due Date M before M before                                                        Q 1/15,                                  A 3/15                                      A 3/1       M 15th                      SA 2/1, M last A 3/31                              SA                           A 3/1                           A 3/1
                        25th     25th                                                            4/15,                                                                                                                        8/1     day                                        2/1,
                                                                                                 7/15,                                                                                                                                                                           8/1
                                                                                                 10/15
21
22                                                                 Notarized Affidavit
                                                                                                                                                                                                                                                        Due 2/1 for Jul -Dec & 8/1
23                                                           AFFIDAVIT BY SURPLUS LINES BROKER                                                                                                                                                          for Jan-Jun.
     I, as a licensed Surplus Lines Broker, authorized to transact insurance with the surplus lines insurer(s) named on this Quarterly Surplus Lines Premium Tax Report,
     being duly sworn, depose and declare under the penalties provided under law for filing a false affidavit that a diligent effort has been made to procure said insurance
     coverage from licensed insurers which are authorized to transact the class of insurance involved and which accept in the usual course of business, insurance on risks of
     the same class described herein. Furthermore, this insurance was not placed for the purpose of securing lower rates than would be accepted by any authorized insurer.
     This insurance has been procured with the surplus line insurer(s) named on this Quarterly Surplus Lines Premium Tax Report, which insurance is only the excess over
24   amounts procurable from licensed insurers.
25
26 Surplus Lines Broker Signature: _____________________________________________
27 Printed Name: ______________________________________________________________
28 Dated: ___________________________________________


                  16e8709a-febd-42fd-b55f-598fcc306123.xls 11/14/2010
                  A                     BY             BZ          CA          CB           CC            CD            CE           CF           CG            CH              CI       CJ         CK          CL        CM        CN          CO         CP        CQ          CR        CS       CT      CU         CV          CW        CX
1                                                   QUARTERLY SURPLUS LINES                                                             PREMIUM TAX REPORT
2
3 Risks Placed during (quarter ending) _________________ of 20 ____.
4 Surplus Lines Producer Name _____________________________________________
5 NPN #                                      License #                      License #                                                                      License #                             License #                      License #                             License #                             License #
6                                               25                              5                                                                             94                                  35588                          6546546                               734958                                357951
7                                            Kentucky                       Louisiana                                                                       Maine                                Maryland                      Massachusetts                          Michigan                              Minnesota


                                                      Mult                                     Mult by                Mult               Mult by                   Mult by                                                                                                 Mult by                            Mult
                                                     by Tax          Lloyd's                    Tax                  by Tax               Tax                       Tax                                                                                                     Tax    Other Tax                 by Tax Stamp
        Insured’s Name &                %             Rate Surcharg Attorney-    %              Rate   %              Rate  %             Rate       %              Rate       %                                                                                            Rate (Regulatory    %             Rate   Fee     %
8        Location of Risk           Allocated Premium 3%      e      in-Fact Allocated Premium  5% Allocated Premium 3% Allocated Premium 3%     Allocated Premium  4%     Allocated                                                                               Premium  2%     Fee) .5% Allocated Premium 3%    .25% Allocated
     Jim Roe Indianapolis,
9    IN                                                      0         0                                                       0          0                            0             0                    0           0                   0          0                     0           0        0                0           0           0
     Jerry Roush
10   Noblesville, IN                                         0         0                                                       0          0                            0             0                    0           0                   0          0                     0           0        0                0           0           0
     Goerge Smith 1527 N
11   21st, St. Nerriille IN                                  0         0                                                       0          0                            0             0                    0           0                   0          0                     0           0        0                0           0           0
     Aron Lea 2929
12   Pendelton Pike,                                         0         0                                                       0          0                            0             0                    0           0                   0          0                     0           0        0                0           0           0
     Big Earls Bar 225 N
13   2nd St. Vincennes, IN                                   0         0                                                       0          0                            0             0                    0           0                   0          0                     0           0        0                0           0           0
     Luv & Stuff Cartoons,
14   Evansville IN                                           0         0                                                       0          0                            0             0                    0           0                   0          0                     0           0        0                0           0           0
     John Doe 12345 Main
15   Street Anytown TX                   1.50%              60         2                                   7.00%            280         14        1.00%              40              1   1.00%           40           1   1.00%          40          2     1.00%          40           1        0   1.00%      40            1           0   1.00%

16 Same as above                         1.50%              90         3                                   7.00%            420         21        1.00%              60              2   1.00%           60           2   1.00%          60          2     1.00%          60           1        0   1.00%      60            2           0   1.00%

17 Same as above                         1.50%              90         3                                   7.00%            420         21        1.00%              60              2   1.00%           60           2   1.00%          60          2     1.00%          60           1        0   1.00%      60            2           0   1.00%

18                                                           0         0                                                       0          0                            0             0                    0           0                   0          0                     0           0        0                0           0           0

19                                                           0         0                                                       0          0                            0             0                    0           0                   0          0                     0           0        0                0           0           0

20 Totals                                                240           7                                                  1,120          56                         160              5                160             5                160             6               160             3        1             160            5           0
   Frequency & Due Date                                          Q 1/30,                                                           Q 3/1,                                  Q 3/1,                             SA                              A 1/31                           SA                                    SA          SA
                                                                 4/30,                                                             6/1, 9/1,                               4/30,                              3/15,                                                            2/15,                                 2/15,       2/15,
                                                                 7/30,                                                             12/1                                    6/30,                              9/15                                                             8/15                                  8/15        8/15
                                                                 10/30                                                                                                     10/31
21
22

23                                                          AFFIDAVIT BY SURPLUS LINES BROKER
     I, as a licensed Surplus Lines Broker, authorized to transact insurance with the surplus lines insurer(s) named on this Quarterly Surplus Lines Premium Tax Report,
     being duly sworn, depose and declare under the penalties provided under law for filing a false affidavit that a diligent effort has been made to procure said insurance
     coverage from licensed insurers which are authorized to transact the class of insurance involved and which accept in the usual course of business, insurance on risks of
     the same class described herein. Furthermore, this insurance was not placed for the purpose of securing lower rates than would be accepted by any authorized insurer.
     This insurance has been procured with the surplus line insurer(s) named on this Quarterly Surplus Lines Premium Tax Report, which insurance is only the excess over
24   amounts procurable from licensed insurers.
25
26 Surplus Lines Broker Signature: _____________________________________________
27 Printed Name: ______________________________________________________________
28 Dated: ___________________________________________


                  16e8709a-febd-42fd-b55f-598fcc306123.xls 11/14/2010
                  A                     CY          CZ         DA            DB              DC            DD          DE          DF           DG          DH          DI           DJ       DK      DL        DM       DN     DO       DP          DQ      DR          DS        DT         DU         DV      DW        DX         DY
1                                                  QUARTERLY SURPLUS                                                      LINES PREMIUM TAX REPORT
2
3 Risks Placed during (quarter ending) _________________ of 20 ____.
4 Surplus Lines Producer Name _____________________________________________
5 NPN #                             License #                        License #                                                                         License #                                      License #                          License #                              License #                        License #
6                                    654987                           491526                                                                            857346                                         764259                             919191                                5957555                          77733344
7                                  Mississippi                       Missouri                                                                          Montana                                        Nebraska                            Nevada                              New Hampshire                      New Jersey


                                             Mult                                    Mult                                                                  Mult        Other                       Mult                                          Mult                          Mult by                   Mult
                                            by Tax Stamp                            by Tax                                                                by Tax Stamp Tax (Fire                  by Tax Fire                                   by Tax                          Tax                     by Tax
        Insured’s Name &                     Rate   Fee  Wind Pool     %             Rate   %                                                              Rate   Fee Marshal)       %             Rate Marshal                   %              Rate Stamp      %              Rate       %             Rate                         Fire
8        Location of Risk           Premium 4%     .25% Assessment Allocated Premium 5% Allocated Premium                                                 2.75% 1% .25%          Allocated Premium 3%    Tax                  Allocated Premium 3.5% Fee .4% Allocated Premium  2%     Allocated Premium 3%                           Tax
     Jim Roe Indianapolis,
9    IN                                       0         0          0                                            0          0                          0         0            0            0                0        0                          0        0         0                     0          0                  0       0
     Jerry Roush
10   Noblesville, IN                          0         0          0                                            0          0                          0         0            0            0                0        0                          0        0         0                     0          0                  0       0
     Goerge Smith 1527 N
11   21st, St. Nerriille IN                   0         0          0                                            0          0                          0         0            0            0                0        0                          0        0         0                     0          0                  0       0
     Aron Lea 2929
12   Pendelton Pike,                          0         0          0                                            0          0                          0         0            0            0                0        0                          0        0         0                     0          0                  0       0
     Big Earls Bar 225 N
13   2nd St. Vincennes, IN                    0         0          0                                            0          0                          0         0            0            0                0        0                          0        0         0                     0          0                  0       0
     Luv & Stuff Cartoons,
14   Evansville IN                            0         0          0                                            0          0                          0         0            0            0                0        0                          0        0         0                     0          0                  0       0
     John Doe 12345 Main
15   Street Anytown TX                      40          2          0                          4.00%          160           8       1.00%            40          1            0            0   2.00%     80          2           1.00%         40        1         0      1.00%        40           1     1.00%      40        1

16 Same as above                            60          2          0                          4.00%          240         12        1.00%            60          2            1            0   2.00%    120          4           1.00%         60        2         0      1.00%        60           1     1.00%      60        2

17 Same as above                            60          2          0                          4.00%          240         12        1.00%            60          2            1            0   2.00%    120          4           1.00%         60        2         0      1.00%        60           1     1.00%      60        2

18                                            0         0          0                                            0          0                          0         0            0            0                0        0                          0        0         0                     0          0                  0       0

19                                            0         0          0                                            0          0                          0         0            0            0                0        0                          0        0         0                     0          0                  0       0

20 Totals                                   160        6      0                                               640       32                          160           4           2           0            320          10                      160           6       1                   160            3              160           5
   Frequency & Due Date                           M 15th M      M 15th                                              A 3/1                                 A 4/1       A 4/1       A 4/1                        A 2/15                              Q 2/15, M last                           A 1/31                        Q
                                                         15th                                                                                                                                                                                      5/15, day                                                              2/15,
                                                                                                                                                                                                                                                   8/15,/                                                                 5/15,
                                                                                                                                                                                                                                                   11/15                                                                  8/15,
21                                                                                                                                                                                                                                                                                                                        11/15
22                                                                                                                             Notarized Affidavit                                                                                                                    Notarized Annual Report

23                                                          AFFIDAVIT BY SURPLUS LINES BROKER
     I, as a licensed Surplus Lines Broker, authorized to transact insurance with the surplus lines insurer(s) named on this Quarterly Surplus Lines Premium Tax Report,
     being duly sworn, depose and declare under the penalties provided under law for filing a false affidavit that a diligent effort has been made to procure said insurance
     coverage from licensed insurers which are authorized to transact the class of insurance involved and which accept in the usual course of business, insurance on risks of
     the same class described herein. Furthermore, this insurance was not placed for the purpose of securing lower rates than would be accepted by any authorized insurer.
     This insurance has been procured with the surplus line insurer(s) named on this Quarterly Surplus Lines Premium Tax Report, which insurance is only the excess over
24   amounts procurable from licensed insurers.
25
26 Surplus Lines Broker Signature: _____________________________________________
27 Printed Name: ______________________________________________________________
28 Dated: ___________________________________________


                  16e8709a-febd-42fd-b55f-598fcc306123.xls 11/14/2010
                  A                     DZ           EA           EB            EC            ED           EE         EF          EG            EH          EI           EJ           EK           EL           EM           EN           EO      EP         EQ         ER       ES        ET           EU         EV          EW          EX       EY
1                                                  QUARTERLY SURPLUS                                                       LINES PREMIUM TAX REPORT
2
3 Risks Placed during (quarter ending) _________________ of 20 ____.
4 Surplus Lines Producer Name _____________________________________________
5 NPN #                             License #                      License #                                                             License #                               License #                               License #                        License #                              License #                                          License #
6                                    222222                          333333                                                               142536                                    600                                    8888                             7777                                  22288                                              3133131
7                                 New Mexico                       New York                                                            North Carolina                           North Dakota                               Ohio                           Oklahoma                                Oregon                                           Pennsylvania


                                                                                 Mult                          Mult                   Mult by                                                                                      Mult                                                          Mult by Stamp   Other
                                                      Mult by                   by Tax                        by Tax                   Tax                                                                                        by Tax                Mult by                                   Tax Fee $15 Tax (Fire
        Insured’s Name &                %               Tax       %              Rate Stamp      %             Rate                    Rate     %                                                                                  Rate   %               Tax       %                             Rate    Per   Marshal     %
8        Location of Risk           Allocated Premium Rate 3% Allocated Premium 3.6% Fee .2% Allocated Premium 5% % Allocated Premium 1.75% Allocated                                                                     Premium  5% Allocated Premium Rate 6% Allocated                Premium  2%     Policy Tax) 1% Allocated Premium
     Jim Roe Indianapolis,
9    IN                                                    0           0                            0          0           0                         0           0                          0            0                           0       0                    0          0                   0           0        15            0                    0
     Jerry Roush
10   Noblesville, IN                                       0           0                            0          0           0                         0           0                          0            0                           0       0                    0          0                   0           0        15            0                    0
     Goerge Smith 1527 N
11   21st, St. Nerriille IN                                0           0                            0          0           0                         0           0                          0            0                           0       0                    0          0                   0           0        15            0                    0
     Aron Lea 2929
12   Pendelton Pike,                                       0           0                            0          0           0                         0           0                          0            0                           0       0                    0          0                   0           0        15            0                    0
     Big Earls Bar 225 N
13   2nd St. Vincennes, IN                                 0           0                            0          0           0                         0           0                          0            0                           0       0                    0          0                   0           0        15            0                    0
     Luv & Stuff Cartoons,
14   Evansville IN                                         0           0                            0          0           0                         0           0                          0            0                           0       0                    0          0                   0           0        15            0                    0
     John Doe 12345 Main
15   Street Anytown TX                  5.00%          200             6        8.00%            320         12            1      1.00%            40            2         1.00%           40            1       1.00%             40        2    3.50%        140           8   1.00%          40           1        15            0      1.00%       40

16 Same as above                        5.00%          300             9        8.00%            480         17            1      1.00%            60            3         1.00%           60            1       1.00%             60        3    3.50%        210        13     1.00%          60           1        15            1      1.00%       60

17 Same as above                        5.00%          300             9        8.00%            480         17            1      1.00%            60            3         1.00%           60            1       1.00%             60        3    3.50%        210        13     1.00%          60           1        15            1      1.00%       60

18                                                         0           0                            0          0           0                         0           0                          0            0                           0       0                    0          0                   0           0        15            0                    0

19                                                         0           0                            0          0           0                         0           0                          0            0                           0       0                    0          0                   0           0        15            0                    0

20 Totals                                               800          24                        1,280        46        3                            160           8                         160           3                         160        8                560          34                  160         3          165             2              160
   Frequency & Due Date                                        Q 2/28,                                  A 3/15 M last                                    Q                                       A 4/1                                   A 1/31                       Q 1/31,                         Q 2/15,    Q 2/15,     Q 2/15,
                                                               5/30,                                           day                                       1/30,                                                                                                        4/30,                           5/15,      5/15,       5/15,
                                                               8/29,                                                                                     4/30,                                                                                                        7/31,                           8/15,      8/15,       8/15,
                                                               11/29                                                                                     7/30,                                                                                                        10/31                           11/15      11/15       11/15
21                                                                                                                                                       10/30
22                                                                         Notarized Annual Report                                                                   Notarized Affidavit                     Notarized Affidavit

23                                                                  Declinations required
                                                            AFFIDAVIT BY SURPLUS LINES BROKER
     I, as a licensed Surplus Lines Broker, authorized to transact insurance with the surplus lines insurer(s) named on this Quarterly Surplus Lines Premium Tax Report,
     being duly sworn, depose and declare under the penalties provided under law for filing a false affidavit that a diligent effort has been made to procure said insurance
     coverage from licensed insurers which are authorized to transact the class of insurance involved and which accept in the usual course of business, insurance on risks of
     the same class described herein. Furthermore, this insurance was not placed for the purpose of securing lower rates than would be accepted by any authorized insurer.
     This insurance has been procured with the surplus line insurer(s) named on this Quarterly Surplus Lines Premium Tax Report, which insurance is only the excess over
24   amounts procurable from licensed insurers.
25
26 Surplus Lines Broker Signature: _____________________________________________
27 Printed Name: ______________________________________________________________
28 Dated: ___________________________________________


                  16e8709a-febd-42fd-b55f-598fcc306123.xls 11/14/2010
                  A                   EZ          FA            FB           FC           FD           FE            FF           FG           FH            FI          FJ             FK            FL          FM         FN          FO         FP         FQ       FR        FS         FT          FU       FV      FW          FX           FY        FZ
1                                                   QUARTERLY SURPLUS LINES                                                                PREMIUM TAX REPORT
2
3 Risks Placed during (quarter ending) _________________ of 20 ____.
4 Surplus Lines Producer Name _____________________________________________
5 NPN #           License #                         License #            License #                                                                    License #                                     License #                                    License #                        License #                                License #                                 L
6                  3133131                          50505050             3232333                                                                      98989898                                     1111444555                                    8888222                         4554545454                               3444333444                                 6
7                Pennsylvania                      Puerto Rico          Rhode Island                                                                South Carolina                                 South Dakota                                  Tennessee                          Texas                                    Utah                                    V


                                     Mult   Stamp                   Mult by                   Mult by                   Mult                 Mult by                       Mult by                                                                                                      Mult by
                                    by Tax Fee $25                   Tax                       Tax                     by Tax                 Tax                           Tax                                                                                                          Tax    Stamp                Mult by
        Insured’s Name &             Rate    Per       %             Rate       %              Rate       %             Rate   %              Rate Other     %              Rate    %                                                                                                    Rate    Fee   %             Tax Rate Stamp     %
8        Location of Risk            3%     Policy Allocated Premium 9%     Allocated Premium  3%     Allocated Premium 4% Allocated Premium 2.5% Tax 3% Allocated Premium 2.5% Allocated                                                                                       Premium 4.85% .06% Allocated Premium 4.25% Fee .25% Allocated
     Jim Roe Indianapolis,
9    IN                                    0          25                           0           0                           0           0                           0            0                           0         0           0                      0          0                  0           0          0                0            0            0
     Jerry Roush
10   Noblesville, IN                       0          25                           0           0                           0           0                           0            0                           0         0           0                      0          0                  0           0          0                0            0            0
     Goerge Smith 1527 N
11   21st, St. Nerriille IN                0          25                           0           0                           0           0                           0            0                           0         0           0                      0          0                  0           0          0                0            0            0
     Aron Lea 2929
12   Pendelton Pike,                       0          25                           0           0                           0           0                           0            0                           0         0           0                      0          0                  0           0          0                0            0            0
     Big Earls Bar 225 N
13   2nd St. Vincennes, IN                 0          25                           0           0                           0           0                           0            0                           0         0           0                      0          0                  0           0          0                0            0            0
     Luv & Stuff Cartoons,
14   Evansville IN                         0          25                           0           0                           0           0                           0            0                           0         0           0                      0          0                  0           0          0                0            0            0
     John Doe 12345 Main
15   Street Anytown TX                     1          25        1.00%            40            4       1.00%             40            1       1.00%              40            2       1.00%              40         1           1      1.00%         40           1   4.00%       160            8          0   1.00%    40               2            0   1.00%

16 Same as above                           2          25        1.00%            60            5       1.00%             60            2       1.00%              60            2       1.00%              60         2           2      1.00%         60           2   4.00%       240        12             0   1.00%    60               3            0   1.00%

17 Same as above                           2          25        1.00%            60            5       1.00%             60            2       1.00%              60            2       1.00%              60         2           2      1.00%         60           2   4.00%       240        12             0   1.00%    60               3            0   1.00%

18                                         0          25                           0           0                           0           0                           0            0                           0         0           0                      0          0                  0           0          0                0            0            0

19                                         0          25                           0           0                           0           0                           0            0                           0         0           0                      0          0                  0           0          0                0            0            0

20 Totals                     5    275                                          160         14                           160           5                        160             6                        160           4         5                    160          4                640            31        0             160              7            0
   Frequency & Due Date A 1/31 M 25th                                                  A 12/31                                 A 4/1                                   Q                                        A 4/1 -    A 4/1 -                           SA 3/1,                       A 3/1        M 30th                     M 25th       M 25th
                                                                                                                                                                       1/30,                                    Q 1/31,    Q 1/31,                           9/1
                                                                                                                                                                       4/30,                                    4/30,      4/30,
                                                                                                                                                                       7/30,                                    7/31,      7/31,
21                                                                                                                                                                     10/30                                    10/31      10/31
22                                                                                                 Notarized Affidavit                                                                                                                Notarized Affidavit
                                                                                                                                                                                    If SL agt pays over $5,000 in SL prem tax, must
23                                                          AFFIDAVIT BY SURPLUS LINES BROKER                                                                                       report on quarterly basis.
     I, as a licensed Surplus Lines Broker, authorized to transact insurance with the surplus lines insurer(s) named on this Quarterly Surplus Lines Premium Tax Report,
     being duly sworn, depose and declare under the penalties provided under law for filing a false affidavit that a diligent effort has been made to procure said insurance
     coverage from licensed insurers which are authorized to transact the class of insurance involved and which accept in the usual course of business, insurance on risks of
     the same class described herein. Furthermore, this insurance was not placed for the purpose of securing lower rates than would be accepted by any authorized insurer.
     This insurance has been procured with the surplus line insurer(s) named on this Quarterly Surplus Lines Premium Tax Report, which insurance is only the excess over
24   amounts procurable from licensed insurers.
25
26 Surplus Lines Broker Signature: _____________________________________________
27 Printed Name: ______________________________________________________________
28 Dated: ___________________________________________


                  16e8709a-febd-42fd-b55f-598fcc306123.xls 11/14/2010
                  A                     GA            GB            GC             GD            GE             GF            GG            GH             GI            GJ      GK          GL          GM          GN      GO          GP       GQ          GR         GS          GT        GU           GV          GW
1                                                  QUARTERLY SURPLUS                                                      LINES PREMIUM TAX REPORT
2
3 Risks Placed during (quarter ending) _________________ of 20 ____.
4 Surplus Lines Producer Name _____________________________________________
5 NPN #                   License #                     License #                                                               License #                                          License #                                 License #                               License #                           License #
6                         6666620                        1111110                                                                 3030303                                           4444442                                    300050                                 88552213
7                         Vermont                        Virginia                                                               Washington                                        West Virginia                              Wisconsin                               Wyoming                        Foreign Country (ies)


                                                                                                                                                                        Mult                        Mult by
                                            Mult by                    Mult by                 Mult by                             Mult by Other Tax                   by Tax Other                  Tax                                                                                                              Mult by
        Insured’s Name &                    Tax Rate     %             Tax Rate  %             Tax Rate Stamp        %             Tax Rate (Regulatory   %             Rate   Tax    %              Rate       %                                                                                                     Tax Rate
8        Location of Risk           Premium   3%     Allocated Premium 2.25% Allocated Premium   2%     Fee .25% Allocated Premium   4%      Fee) .5% Allocated Premium 3%    .5% Allocated Premium  3%     Allocated                                                                                    Premium        3%
     Jim Roe Indianapolis,
9    IN                                       0             0                            0             0                            0             0              0                    0           0            0                  0       0        0                          0            0                      0          0
     Jerry Roush
10   Noblesville, IN                          0             0                            0             0                            0             0              0                    0           0            0                  0       0        0                          0            0                      0          0
     Goerge Smith 1527 N
11   21st, St. Nerriille IN                   0             0                            0             0                            0             0              0                    0           0            0                  0       0        0                          0            0                      0          0
     Aron Lea 2929
12   Pendelton Pike,                          0             0                            0             0                            0             0              0                    0           0            0                  0       0        0                          0            0                      0          0
     Big Earls Bar 225 N
13   2nd St. Vincennes, IN                    0             0                            0             0                            0             0              0                    0           0            0                  0       0        0                          0            0                      0          0
     Luv & Stuff Cartoons,
14   Evansville IN                            0             0                            0             0                            0             0              0                    0           0            0                  0       0        0                          0            0                      0          0
     John Doe 12345 Main
15   Street Anytown TX                      40              1        1.00%             40              1        1.00%             40              1              0       1.00%     40             2            0     1.00%      40        1        0           0.50%        20             1   0.50%             20          1

16 Same as above                            60              2        1.00%             60              1        1.00%             60              1              0       1.00%     60             2            0     1.00%      60        2        0           0.50%        30             1   0.50%             30          1

17 Same as above                            60              2        1.00%             60              1        1.00%             60              1              0       1.00%     60             2            0     1.00%      60        2        0           0.50%        30             1   0.50%             30          1

18                                            0             0                            0             0                            0             0              0                    0           0            0                  0       0        0                          0            0                      0          0

19                                            0             0                            0             0                            0             0              0                    0           0            0                  0       0        0                          0            0                      0          0

20 Totals                                   160              5                         160    4                  160                               3              0                160             6             1              160           5        1                      80           2                     80              2
   Frequency & Due Date                           Q 1/31,                            A 3/1 - Q                       A 3/1                             M last                             A 3/1 - Q A 3/1 - Q                         A 3/1                                        A 3/1
                                                  4/30,                              1/30,                                                             day                                4/25,      4/25, 7/25,
                                                  7/30,                              4/30,                                                                                                7/25,      10/25
                                                  10/30                              7/30,                                                                                                10/25
21                                                                                   10/30
22                                                               Notarized Annual Report        Notarized Affidavit                                                                                                                                        Notarized Affidavit

23                                                          AFFIDAVIT BY SURPLUS LINES BROKER
     I, as a licensed Surplus Lines Broker, authorized to transact insurance with the surplus lines insurer(s) named on this Quarterly Surplus Lines Premium Tax Report,
     being duly sworn, depose and declare under the penalties provided under law for filing a false affidavit that a diligent effort has been made to procure said insurance
     coverage from licensed insurers which are authorized to transact the class of insurance involved and which accept in the usual course of business, insurance on risks of
     the same class described herein. Furthermore, this insurance was not placed for the purpose of securing lower rates than would be accepted by any authorized insurer.
     This insurance has been procured with the surplus line insurer(s) named on this Quarterly Surplus Lines Premium Tax Report, which insurance is only the excess over
24   amounts procurable from licensed insurers.
25
26 Surplus Lines Broker Signature: _____________________________________________
27 Printed Name: ______________________________________________________________
28 Dated: ___________________________________________


                  16e8709a-febd-42fd-b55f-598fcc306123.xls 11/14/2010
               NAIC Annual Statement Lines of Business

         1.0   Fire
         2.0   Allied lines
         3.0   Farmowners multiple peril
         4.0   Homeowners multiple peril
         5.0   Commercial multiple peril
         6.0   Mortgage guaranty
         8.0   Ocean marine
         9.0   Inland marine
       10.0    Financial guaranty
       11.1    Medical professional liability—occurrence
       11.2    Medical professional liability—claims-made
       12.0    Earthquake
       13.0    Group accident and health
       14.0    Credit accident and health (group and individual)
       15.0    Other accident and health
       16.0    Workers' compensation
       17.1    Other liability—occurrence
       17.2    Other liability—claims-made
       17.3    Excess Workers’ Compensation
       18.1    Products liability—occurrence
       18.2    Products liability—claims-made
19.1, 19.2     Private passenger auto liability
19.3, 19.4     Commercial auto liability
       21.0    Auto physical damage
       22.0    Aircraft (all perils)
       23.0    Fidelity
       24.0    Surety
       26.0    Burglary and theft
       27.0    Boiler and machinery
       28.0    Credit
       29.0    International
       30.0    Warranty
       31.0    Reinsurance-Nonproportional Assumed Property
       32.0    Reinsurance-Nonproportional Assumed Liability
       33.0    Reinsurance-Nonproportional Assumed Financial Lines
       34.0    Aggregate write-ins for other lines of business
     STATE                        TYPE             FREQUENCY                  DUE
Alabama               Tax                          Quarterly     5/15, 8/15, 11/15 & 3/1
Alaska                Tax                          Quarterly     5/31, 8/31, 11/30 & 3/1
Alaska                Filing Fee                   Quarterly     5/31, 8/31, 11/30 & 3/1
Arizona               Tax                          Semi-Annual   3/1 & 9/1
Arizona               Stamping Fee                 Monthly       Last day
Arkansas              Tax                          Monthly       10th
California            Tax                          Monthly       1st
California            Stamping Fee                 Monthly       Last day
Colorado              Tax                          Annual        3/1
Connecticut           Tax                          Quarterly     5/1, 8/1, 11/1 & 2/1
Delaware              Tax                          Quarterly     4/30, 7/30, 10/30, 1/30 & 3/1
D.C.                  Tax                          Semi-Annual   2/1 & 8/1
Florida               Tax                          Monthly       Last day
Florida               Stamping Fee                 Monthly       Last day
Florida               EMPA Surcharge               Monthly       Last day
Florida               Hurricane FHCF               Monthly       Last day
Florida               CPIC Emergency Assessment    Monthly       Last day
Georgia               Tax                          Quarterly     4/15, 7/15, 10/15 & 1/15
Hawaii                Tax                          Annual        3/15
Idaho                 Tax                          Annual        3/1
Idaho                 Stamping Fee                 Monthly       15th
Illinois              Tax                          Semi-Annual   3/1 & 8/1
Illinois              Stamping Fee                 Monthly       Last day
Illinois              Fire Marshall Tax            Annual        3/31
Indiana               Tax                          Semi-Annual   2/1 & 8/1
Iowa                  Tax                          Annual        3/1
Kansas                Tax                          Annual        3/1
Kentucky              Tax                          Quarterly     7/30, 10/30, 1/30 & 4/30
Kentucky              Municipal Tax (Each Muni)*   Quarterly     7/30, 10/30, 1/30 & 4/30
Kentucky              Surcharge*                   Monthly       20th
Kentucky              Lloyds Service Fee*
Kentucky              Lloyds Municipal Tax*
Kentucky              Lloyds Surcharge*
Louisiana             Tax                          Quarterly     6/1, 9/1, 12/1 & 3/1
Maine                 Tax                          Quarterly     4/30, 6/25, 10/31 & 3/1
Maryland              Tax                          Quarterly     4/15, 6/15, 9/15, 12/15 & 3/15
Massachusetts         Tax                          Annual        1/31
Michigan              Tax                          Semi-Annual   2/15 & 8/15
Minnesota             Tax                          Semi-Annual   2/15 & 8/15
Minnesota             Stamping Fee                 Semi-Annual   2/15 & 8/15
Mississippi           Tax                          Monthly       15th
Mississippi           Stamping Fee                 Monthly       15th
Mississippi           Windstorm Policy Fee         Monthly       15th
Missouri              Tax                          Annual        3/1
Montana               Tax                          Annual        4/1
Montana               Stamping Fee                 Annual        4/1
Montana               Fire Tax                     Annual        4/1
Nebraska              Tax                          Quarterly     4/30, 7/30, 10/30, 1/30 & 2/15
Nevada                Tax                          Annual        3/1
Nevada                Stamping Fee                 Monthly       Last day
New Hampshire         Tax                          Annual        1/31
New Jersey            Tax                          Quarterly     5/15, 8/15 11/15 & 2/14
New Mexico            Tax                          Quarterly     5/30, 8/29, 11/29 & 2/28
New York              Tax                          Annual        3/15

*Kentucky has 389 separate municipalities
*South Carolina has 46 separate municipalities
    STATE                         TYPE           FREQUENCY                  DUE
New York              Stamping Fee               Annual        Last day
North Carolina        Tax                        Quarterly     4/30, 7/30, 10/30 & 1/30
North Dakota          Tax                        Annual        4/1
Ohio                  Tax                        Annual        1/31
Oklahoma              Tax                        Quarterly     4/30, 7/30, 10/30, 1/31 & 4/1
Oregon                Tax                        Quarterly     5/15, 8/15, 11/15 & 2/15
Oregon                SL Service Charge          Quarterly     5/15, 8/15, 11/15 & 2/15
Oregon                Fire Marshall Tax          Quarterly     5/15, 8/15, 11/15 & 2/15
Pennsylvania          Tax                        Annual        1/31
Pennsylvania          Stamping Fee               Monthly       25th
Rhode Island          Tax                        Quarterly     4/30, 7/30, 10/30, 12/31 & 4/1
South Carolina        Tax                        Quarterly     4/30, 7/30, 10/30, 1/30 & 3/1
South Carolina        Municipal Tax *            Annual        1/31
South Dakota          Tax                        Quarterly     4/30, 7/31, 10/31, 1/31 & 4/1
South Dakota          SL Fire Tax                Quarterly     4/30, 7/31, 10/31, 1/31 & 4/1
Tennessee             Tax                        Semi-Annual   3/1 & 9/1
Tennessee             SL Fire Tax                Semi-Annual   3/1 & 9/1
Texas                 Tax                        Monthly       15th
Texas                 Stamping Fee               Monthly       30th
Utah                  Tax                        Monthly       Last day
Vermont               Tax                        Quarterly     4/30, 7/30, 9/30 & 12/31
Virginia              Tax                        Quarterly     4/30, 7/30, 10/30, 1/30 & 3/1
Washington            Tax                        Annual        3/1
Washington            Stamping Fee               Monthly       Last day
West Virginia         Tax                        Quarterly     4/25, 7/25, 10/25 & 3/25
West Virginia         Surcharge                  Quarterly     4/25, 7/25, 10/25 & 3/25
Wisconsin             Tax                        Annual        3/1
Wyoming               Tax                        Annual        3/1

*Kentucky has 389 separate municipalities
*South Carolina has 46 separate municipalities




*Kentucky has 389 separate municipalities
*South Carolina has 46 separate municipalities

				
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