N.M. Admin. Code § 13.19.2.21
SURPLUS LINES INSURER ANNUAL SUMMARY REPORT
Name of insurer __________________________________
Address of insurer: __________________________________
NAIC company code or alien listing code: __________________________________
The insurer hereby submits to the New Mexico department of insurance a summary of all surplus lines insurance provided by the insurer for risks in New Mexico during _________.
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 of authorized officer Date
__________________________________
Title of authorized officer
N.M. Admin. Code § 13.19.2.21