Custodial Bank Deposit New Account Packet

Includes Form E-003, E-125 and instructions on how to establish an account for applicants who elect to use marketable securities to satisfy a financial security requirement.

Form E150 - Assignment of Certificate of Deposit or Time Deposit to Arizona State Treasurer
Form E230: Change to Domestic Insurer Statutory Agent
Administrative Order 00A-123-INS: Investment Grade Ratings for and Eligibility of Investments in Obligations and Preferred Stock under A.R.S. §§ 20-544 and 20-545
Form E110: Biographical Affidavit
Captive Insurer Annual Report and Renewal Fee Transmittal
Captive Insurer Audited Financial Report Exemption Standards and Filing Requirements
Captive Insurer Quarterly and Annual Statement Filings for Risk Retention Group - NAIC Note 1
Form E110: Biographical Affidavit
Administrative Order 00A-123-INS: Investment Grade Ratings for and Eligibility of Investments in Obligations and Preferred Stock under A.R.S. §§ 20-544 and 20-545
Credit Property Experience Report, Annual Statement Supplement
Form E125: Security Deposit Form
Form E126: Security Release Form
Form E-857: Bond of Service Company
Form E-800: Application for Service Company Permit

This is the primary application form for a service company permit.  The form and its instructions identify other documents you must submit with this form.  You must complete the form on a computer - do not print it out until it is complete and all requirements are satisfied.

Form E-811: Renewal of Service Company Permit
Form E-801: Motor Vehicle Dealer's Notice of Intent

A motor vehicle service contract administrator or insurer must use this form and submit a fee to file an application for approval of a motor vehicle service contract program.  ARS § 20-1095.06.

Form E-800-B: Service Company Biographical List

Complete this form to report:

  • All members of the board of directors/trustees, members of the executive committee or any other governing board of the committee; and,
  • If applicant is a corporation, all officers and all shareholders that directly or indirectly own 25% or more of the voting securities of the applicant if a corporation; and,
  • If applicant is a partnership or association, all partners.

IMPORTANT! The Department will investigate information provided and may deny or refuse to renew a permit if the applicant fails to provide complete and truthful information about itself and the individuals responsible for the service company’s affairs.

Form E-820: Service Company Application Checklist

The Department of Insurance uses this document to determine whether an application meets the requirements under Arizona law. Use this document to check your application before you submit it.

Form EXSAPP: Application for Workers' Compensation Deposit Reduction - Instructions
Form E126XS: Application and Order for Release of Excess Deposit

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