PURPOSE: This rule prescribes forms to be followed in making filings pursuant to sections 384.031 and 384.057, RSMo and effectuates or aids in the interpretation of sections 384.017(2), 384.031 and 384.057, RSMo.

1. (1) Forms.

   1. (A) Appendix 1 of this rule, included herein, is the form prescribed by the director for the confidential written report required by section 384.031, RSMo.
   2. (B) Appendix 3 of this rule, included herein, is the form prescribed by the director for the annual report required by section 384.057, RSMo.

2. (2) Proof of filing will be provided to the surplus lines licensee making the filings if the surplus lines licensee encloses a duplicate copy of filings and a self-addressed, stamped envelope. MISSOURI DEPARTMENT OF INSURANCE SURPLUS LINES FILING

   STATE OF MISSOURI—DEPARTMENT OF INSURANCE PO BOX 690, JEFFERSON CITY, MO 65102

   (SUBMIT IN DUPLICATE)

______________________________________________________% __________________________________________________________ SURPLUS LINE INSURER AND % OF PARTICIPATION

______________________________________________________% __________________________________________________________ SURPLUS LINE INSURER AND % OF PARTICIPATION

1. 1. NAME AND ADDRESS OF INSURED:
2. 2. COMPLETE DESCRIPTION OF RISK AND ITS LOCATION: __________________________________________________________ ____________________________________________________________________________________________________________________
3. 3. COMPLETE DESCRIPTION OF COVERAGE (no abbreviation): __________________________________________________________ ____________________________________________________________________________________________________________________
4. 4. SPECIFIC REASON FOR SURPLUS LINES PLACEMENT: ____________________________________________________________________________________________________________________
5. 5. IF MULTI-STATE RISK, ALLOCATION BASIS MUST BE ATTACHED.
6. 6. POLICY NUMBER __________________________________

DATE TERMINATES____________________________________ (If multi-state coverage, attach tax allocation basis) 7. IF NOT A DIRECT PLACEMENT WITH SURPLUS LINES INSURER(S), NAME AND ADDRESS OF AMERICAN BROKERAGE FIRM OF LLOYD’S CORRESPONDENT:

____________________________________________________________________________________________________________________ NAME ADDRESS

THIS PORTION TO BE USED FOR AMENDED FILINGS ONLY

(Fill in above: RISK #, SURPLUS LINES LICENSEE’S NAME and NAME AND ADDRESS OF INSURED)

THE FOLLOWING INFORMATION IS HEREBY MADE A PART OF THE ABOVE NUMBERED ORIGINAL FILING

ADDITIONAL PREMIUM ______________________________

RETURN PREMIUM ___________________________________

ADDITIONAL INFORMATION NOT SUBMITTED ON ORIGINAL FILING: _________________________________________________ ____________________________________________________________________________________________________________________

I DO HEREBY CERTIFY TO THE BEST OF MY KNOWLEDGE, THAT THE ABOVE IS A TRUE AND ACCURATE RECORD OF THE SURPLUS LINES INSURANCE PROCURED PURSUANT TO CHAPTER 384, RSMO __________________________________________

______________________________________________________ DIRECTOR OF INSURANCE FILED:_______________________________________________

THIS FORM IS DUE WITHIN THIRTY (30) DAYS OF THE EFFECTIVE DATE OF COVERAGE. APPENDIX 1

RISK #_____________________________________________________

SURPLUS LINES LICENSEE

PRODUCER

__________________________________________________________ __________________________________________________________ __________________________________________________________

__________________________________________________________

DATE EFFECTIVE_________________________________________

PREMIUM EFFECTIVE ____________________________________

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DATE EFFECTIVE _________________________________________

DATE EFFECTIVE _________________________________________

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__________________________________________________________ SURPLUS LINES LICENSEE’S SIGNATURE

AUTHORITY: sections 374.045, 384.017, 384.031 and 384.057, RSMo 2000.* This rule was previously filed as 4 CSR 190-10.103. Original rule filed May 4, 1987, effective Aug. 1, 1987. Emergency rule filed June 2, 1987, effective July 1, 1987, expired Sept. 1, 1987. Emergency rescission filed June 16, 1987, effective June 26, 1987, expired Aug. 1, 1987. Amended: Filed Jan. 17, 1990, effective May 1, 1990. Amended: Filed April 23, 1999, effective Nov. 30, 1999. Amended: Filed July 12, 2002, effective Feb. 28, 2003.

*Original authority: 374.045, RSMo 1967, amended 1993, 1995; 384.017, RSMo 1987, amended 1989; 384.031, RSMo 1987, amended 1989; and 384.057, RSMo 1987, amended 1989.