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).
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.
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.
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.
Complete this form to report:
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.
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.
Must be completed by each partner, officer, and director, and each other entity owning 25% or more of a Service Company applicant.