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The document is a report form required by the Pennsylvania Insurance Department for transactions with unlicensed insurers, in compliance with the Surplus Lines provisions of the Insurance Company Law. It includes declarations by the producer regarding efforts to obtain insurance from licensed companies, details about the insured's operation, and necessary disclosures about the insurer's status and potential insolvency risks.

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Versions	Form popularity	Fillable & printable
2012	4.8 Satisfied (125 Votes)
2010	4.4 Satisfied (103 Votes)
2008	4 Satisfied (60 Votes)

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