Form E126: Security Release Form

Warning - Phishing Scam

We are aware of a phishing scam targeting insurance professionals claiming that the National Association of Insurance Commissioners received a complaint that the professional submitted a falsified claim. This fraudulent email displays the NAIC and CIPR logos, can originate from what appears to be an naic.org or gmail.com email account, and instructs the recipient to click on a link to download the complaint notification.

Certain antivirus products will detect this as a malicious email.  If you receive a similar email and have any concerns, contact the NAIC Service Desk at (816) 783-8500 or [email protected].

Form E125: Security Deposit 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.

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 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
Form E126-CD: Request for Release of Certificate of Deposit
Form E125-CD: Certificate of Deposit Transmittal
Form E126LOC: Request for Release of Letter of Credit
Form E150 - Assignment of Certificate of Deposit or Time Deposit to Arizona State Treasurer
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.