(a) Within forty-five (45) days after placing any surplus line insurance for an insured whose home state is this state, each surplus lines broker shall execute and file a report regarding the insurance coverage which shall be kept confidential by the commissioner, including the following:
(i) The name and address of the insured;
(ii) The identity of the insurer or insurers;
(iii) A description of the subject and location of the risk;
(iv) The amount of premium charged for the insurance;
(v) Tax allocation information detailing the portion of the premium attributable to properties, risks or exposures located in each state; and (vi) Any other information as may be required by the commissioner.
(b) The report shall be in the form and manner prescribed by the commissioner.