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California: (Attach D1 or D2) <br />Surplus Lines Broker Name <br />Address of the Licensee: <br />License number: <br />Surplus Lines Premium: <br />Alliant Insurance Services, Inc. <br />701 B Street, 6th Floor <br />San Diego, CA 92101 <br />OC36861 <br />$200.00 <br />Surplus Lines Tax: $6.00 <br />Surplus Lines Stamping Fee: $0.36 <br />RISK MmagtAnad UlMsiaR <br />o �RaN, REVIEWED & APPROVED BY: <br />o� A',� Acev44 <br />® Risk Management Specialist <br />