Form T-71a - Surplus Line Broker Return Of Gross Premiums - 2014 Page 3

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State of Rhode Island and Providence Plantations
2014 Form T-71A
14111799990103
Surplus Line Broker Return of Gross Premiums
Name
Federal employer identification number/social security number
For policies invoiced from January 1, 2014 through December 31, 2014
Carrier
Name of
Risk
Invoice
Return
Additional
Company carrying the risk,
NAIC#
Premium
not the Wholesale Broker
Name
Insured
Location
Date
Premium
Premium
Premium totals - - - >
SSN/FEIN:
Signature of broker:
Licensee:

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