N.M. Admin. Code § 13.19.2.20
SURPLUS LINES BROKER QUARTERLY SUMMARY REPORT
(Required by NMSA 1978 Section 59A-14-11 C & D)
Name of broker: __________________________________
Address of broker: __________________________________
License number: __________________________________
I hereby submit to the New Mexico Department of Insurance this summary of all surplus lines insurance I placed during the quarter beginning ____/____/_____and ending ___/____/______. All documents required by Section 59A-14-11 NMSA 1978 and 13 NMAC 19.2.17.3 [now Subsection C of 13.9.2.17 NMAC] to be filed with the superintendent are attached.
I certify that the information on this form is true and correct and is in compliance with the applicable provisions of the New Mexico insurance code and that the information on the diskette filed with this form is identical to the information on the printouts made from the diskette and filed with this form.
__________________________________ ___________________________
Signature Date
SUBSCRIBED AND SWORN TO before me
this ____ day of _____________, ____.
________________________________
Notary Public
My commission expires ____________
N.M. Admin. Code § 13.19.2.20