Affidavit of Business Change of Name

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					                                                 INDIANA DEPARTMENT OF INSURANCE
                                                           MONTHLY REPORT
                                                      Attachment to the AFFIDAVIT
                                                        SURPLUS LINES RISKS

*Risks Placed during (month) _________________ of 20 ____.
Surplus Lines Producer # ______________
Surplus Lines Producer Name _____________________________________________

                                                                                                               Admitted Company’s refusal of
                                                               Premium          Business placed with:                    coverage
  Insured’s Name &     Type of  Date    Term of Amount of Gross             NAIC    Company Name &               NAIC
   Location of Risk   Insurance  of     Coverage Insurance Charged Returned   #    Home Office Address             #      Company Name
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                 Change for 2007-This form with the monthly affidavit is required to be submitted only if business is written.

				
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