A surplus line broker who has procured insurance with an unauthorized insurer for an exempt commercial purchaser must file with the commissioner within sixty days of the procurement (binding or effective date, whichever is later) of the insurance a report of the insurance. The report must be in a format acceptable to the commissioner. The report must include the following information:

(1) Policy or certificate number;

(2) Premium, including any policy fee;

(3) Name and license number of the filing surplus line broker;

(4) Name and address of referring insurance producer (if any);

(5) Name(s) of unauthorized insurer(s);

(6) Name and address of insured;

(7) Binding or effective date, whichever is later;

(8) Brief statement of coverages (common terms may be used); and

(9) Other information as required by the commissioner.