Form T-71a - Surplus Line Broker Return Of Gross Premiums - 2014 Page 2

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State of Rhode Island and Providence Plantations
2014 Form T-71A
14111799990102
Surplus Line Broker Return of Gross Premiums
Name
Federal employer identification number
This page must be completed by agencies/companies with individual licensees covered under this
return to prevent a delay in renewing the licenses of those individuals.
Broker SSN
Broker Name
Broker Address
Broker License Number
SSN/FEIN:
Signature of broker:
Licensee:

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