A. A broker procuring surplus lines insurance on behalf of an insured whose home state is Arizona shall file with the director on or before the date specified in section 20-415, subsection B a verified report setting forth facts from which it may be determined whether the requirements of section 20-407 have been met. The report shall also contain or be accompanied by the following:

1. The name of the insurer and the identification number assigned to it by the national association of insurance commissioners.

2. The number of the policy issued.

3. The name and the city, state and zip code of the insured.

4. The premium, including taxable policy fees.

5. The identity of the specific surplus lines coverage written.

6. The policy effective dates that shall not be open to public inspection.

B. The director shall prescribe the required report form.

C. The director may direct a broker to file the broker’s report required by this section with a voluntary domestic organization of surplus lines brokers with which the director has contracted to accept reports pursuant to section 20-167.

D. A broker may collect from the insured the stamping fee prescribed in section 20-167.

E. The director may impose and collect a civil penalty of not more than $25 against a broker for each day the report prescribed in subsection A of this section is late.

F. In addition to the requirements of subsection A, paragraph 5 of this section, if the insurance coverage is not a recognized surplus line pursuant to section 20-409, a surplus lines broker shall maintain evidence of compliance with the requirements of section 20-407, subsection A for the duration of the insurance policy and for a period of six years after the expiration of the policy.