(a) Within forty-five (45) days after placing any surplus line insurance for an insured whose home state is this state, each surplus lines broker shall execute and file a report regarding the insurance coverage which shall be kept confidential by the commissioner, including the following:

1. (i) The name and address of the insured;
2. (ii) The identity of the insurer or insurers;
3. (iii) A description of the subject and location of the risk;
4. (iv) The amount of premium charged for the insurance;
5. (v) Tax allocation information detailing the portion of the premium attributable to properties, risks or exposures located in each state; and
6. (vi) Any other information as may be required by the commissioner.

(b) The report shall be in the form and manner prescribed by the commissioner.