Submit New Surplus Lines Filing

Complete all required fields to submit a new surplus lines policy filing

Transaction Information

Transaction Type *

Policy Number *

Effective Date *

Expiration Date *

Insured Information

Insured Name *

Address *

City *

State *

ZIP Code *

Coverage Information

Policy Type *

Multiple Locations

Coverage Description *

Insurer Information

Insurer Name *

NAIC Number

Premium & Tax Calculation

Gross Premium *

Diligent Search / Exemptions

Exemption Type *

I certify that a diligent search was completed in accordance with Texas Insurance Code Section 981.004, and that the required coverage cannot be obtained from admitted insurers.

Broker Certification

Broker Name

Robert Martinez

License Number

TX-SL-485721

Company

Southwest Specialty Brokers LLC

Filing Date

2026-01-30

I certify that the information provided in this filing is true and accurate to the best of my knowledge. I understand that false statements may result in penalties under Texas Insurance Code.

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