Form E-200: TPA Registration Application Checklist

NEW AGENCY


Arizona Department of Insurance
100 North 15th Avenue, Suite 261

Phoenix, AZ  85007-2630


Starting July 1, 2020, we became the
Department of Insurance and Financial Institutions (DIFI).


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.

Priority: 
E200
Form L-CLR: Clearance Letter Request

Use this form if:

A.  You are relocating to another state and need to provide a clearance letter from Arizona, OR

B.  You want to permanently surrender insurance license authority.  Be careful!  If you surrender insurance license authority, Arizona law prevents you from reapplying for the surrendered authority for one year. 

Form L-CRT: Certification Letter Request

Information concerning Arizona insurance licenses is available at no charge from the License Search menu option on our web site. Insurance companies and the public are encouraged this License Search feature (rather than a paper printout or a letter of certification) to verify the lines of authority, license issuance and expiration dates, and license status for an Arizona-licensed insurance professional.

Form L-FPV: Fingerprint Verification

This form is to be used by individuals who are required to submit fingerprints as part of an insurance license application. The form includes detailed instructions that must be exactly followed for fingerprints to be accepted by the Department of Insurance and Financial Institutions.

Form L-LOC: Branch Locations

Self Service Storage Agents and Rental Car Agents must specify all office locations from which the entity may transact insurance business.

Form L-LSB: Life Settlement Broker Application

Complete and file this form with the life settlement broker license fee within the first 30 days of operating as a life settlement broker. 

Form L-LTD: Limited License Authority Application

Only use this form to apply for a license as a portable electronics vendor, rental car agent, self-service storage agent, or travel insurance producer. 

Form L-NAV: Application for Navigator or Certified Application Counselor License

The document contains detailed instructions and forms to apply to become a navigator or certified application counselor. 

Form L-PFD: Petition for Determination

You can use this form to ask the Department of Insurance to determine whether a criminal conviction disqualifies you for a license.  

Form L-SURR: License Surrender Request

Only use this form to permanently surrender license authority.  If you wish to clear a license to allow you to become licensed in another state, use Form L-CLR.

Form L-TEMP: Application for a Temporary Insurance License

Submit

  • Form L-TEMP,
  • Form L-152 with a copy of both sides of one of listed forms of identification,
  • Fingerprints and Form L-FPV exactly as described on Form L-FPV, and
  • $142.00 (to cover the $120.00 license fee and $22.00 FBI fingerprint card processing fee). 
NAIC uniform license application for an Individual

To make your application process faster and easier, use NIPR.COM and apply online instead of completing, printing and mailing this application

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.

NAIC Form 11: Biographical Affidavit

Must be completed by each partner, officer, and director, and each other entity owning 25% or more of a Service Company applicant.

Form RO31010: License Application for a Rating Organization
Form RSO31010: License Application for a Rate Service Organization

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