# FISCAL AND REGULATORY

**TAX PAYABLE BY (RE)INSURER(S):** None

**COUNTRY OF ORIGIN:** United States of America

**REGULATORY RISK LOCATION:** 100% United States of America

**OVERSEAS BROKER:** None – Independently Procured by the Insured

**SURPLUS LINE BROKER:** Not Applicable

**STATE OF FILING:** Not Applicable

**US CLASSIFICATION:** Self Procured

**NAIC CODES:** Not Applicable

**ALLOCATION OF PREMIUM TO CODING:** Not Applicable

In respect of electronic lines, please refer to the Settlement Information shown under Security Details herein which is deemed to supersede the above

**ALLOCATION OF PREMIUM TO YEARS OF ACCOUNT:** Not Applicable

In respect of electronic lines, please refer to the Settlement Information shown under Security Details herein which is deemed to supersede the above

**REGULATORY CLIENT CLASSIFICATION:** Commercial - Large Risk

**Policy Number:** CSUSA2304915

**Page:** 18 of 23

**Date:** 16/5/2023 3:30 PM

**CEBBS:** 2023-05-17

**XIS GREAT LAKES**