Name of the Brokerage The SLA Broker Number for the Broker or Brokerage PolicyNumber InsuredName TotalPremium is the sum of all PremiumAmounts in the batch TotalStampingFee is the sum of all StampingFees in the batch For New and Renewal: is this a master policy ? For Renewals: previous policy number For Endorsements enter the endorsement number For New, Renewal and eXtension endorsements: effective date For New, Renewal and eXtension endorsements: expiration date For Cancellations: cancellation date For Binders: binder effective date For Binders: binder expiration date Master Policy Number Master Policy Effective Date Details for each Certificate Certificate Number Certificate Insured Name Certificate Insured Address Certificate effective date Certificate expiration date Certificate Premium Sum of all Certificate Premiums NAICS Code: 6 digit classification Insurance Company or Layering of Insurance Companies Coverage Description Coverage Code (Closest match to SLA published list) Total Coverage Premium is the sum of Coverage_Premium Fees Fee Description Fee Amount Method of allocation used CIC 1775.5 Premium for this state Percentage for this state Total_Premium_all_States Header: Please enter the Policy Number and the California Premium. "hereby submits that he/she is:" or, Section 1: Please enter the name of the Broker Section 1(C): "Name of Nonadmitted Insurer(s)" Full name Layer Number (Primary Policy is layer number 1) Limit of Liability Excess of (underlying limits) Percentage of Layer with GAP Insurers Section A(b) Total Limits of Liability (for all layers combined) Section A(c) Total Percent of GAP Insurers (for all layers combined) Section A(d) This submission is for layer number "Name of GAP Insurer(s)" Full name "hereby submits that he/she is:" or, Name of the Risk Purchasing Group Address of the Risk Purchasing Group Full Name of Admitted Company Check if Employee (E) or Agent (A) First & Last Name of Company Representative Telephone Number "( ) - " or Online Declination Website Month, Year of Declination "MM/YYYY" One or more lines of address information Name of the city Country Name