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California: (Attach D1 or D2) <br /> Surplus Lines Broker Name: Alliant Insurance Services, Inc. <br /> Address of the Licensee: 701 B Street, 6th Floor <br /> San Diego, CA 92101 <br /> License number: 0C36861 <br /> Surplus Lines Premium: $200.00 <br /> Surplus Lines Tax: $6.00 <br /> Surplus Lines Stamping Fee: $0.36 <br /> \ / <br /> REVIEWED&APPROVED BY: <br /> ? I <br /> ® Risk Management Specialist <br />