Form E-100-B: Life and Health Administrator Biographical List

Complete this form to report the name and title of each individual reflected in the count on Form E-100, Item 13, Section E.

Form E-100-A: Life and Health Administrator Registration Addendum

If the applicant uses any name or has any office other than those reported in Section A or B of Form E-100, use this form to report the applicant's complete name and address for all offices in each jurisdiction.  ARS § 20-485.12(B)(6).

Form E-200: TPA Registration Application Checklist

To ensure your application is complete, correct, and meets all registration requirements so the Department can promptly issue a Certificate of Registration, use this document to check your application before you submit it.  The Department uses this document when reviewing applications.

Form E-503-TPA: Affidavit of Lost Certificate of Registration

Complete this form if surrendering a Certificate of Registration that has been misplaced or destroyed.

Form E-115: Life and Health (Third-party) Administrator Information Update

Complete this form to register NEW information that has changed since the TPA was last reported to the Arizona Department of Insurance (ADOI).  It is critical that you update the information with the ACC before filing updated information with the ADOI.

Form L-WAV: Fee Waiver Request

Only use this form (rather than paying the license fee) if you meet all the requirements on the form.  If you file this form, it becomes part of your license application, and if you file incorrect, misleading, incomplete, or materially untrue information on a license application, an insurance license can be denied, suspended or revoked, you could be assessed civil penalties and you could be the subject of other administrative and legal consequences.  The fee waiver only applies to the license fee.  It does not apply to other fees and costs you may need to pay in order to become licensed.

Form E-100: Application for Life and Health Administrator Registration

New version of form posted 4/6/2017 @ 2:45PM.  Use this form to first determine whether you need to apply for a third-party administrator registration.  If the first page of the application indicates you must apply, complete the remainder of the application and include ALL required enclosures along with your fee payment.  An incomplete application will delay your registration and will create additional work for you and for us.

NAIC Form 11: Biographical Affidavit

Must be completed by each partner, officer, and director, and each other individual owning 10% or more of a TPA  applicant.  ARS § 20-485.12(B)(5)

Form E-111: Renewal Application for Life and Health Administrator Registration

IMPORTANT: This form supersedes Form 111.



Due Date:  March 1

You may submit your renewal application after January 1, but the renewal application must be received by the Department of Insurance by March 1.

The application must be certified by two officers of the applicant.  Must be current within 90 days of application filing date.  ARS § 20-485.12(B)(1)(a) and (b)
Form E157: Bond of Life and Health Administrator

Face amount must equal the greater of either (A) 10% of total funds handled for life and health coverage of Arizona residents, or (B) $5,000. Funds handled includes premiums collected for and/or claims paid on behalf of an insurer.  Submit with power of attorney. ARS § 20-485.10

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.