Form L-193: Certificate of Assumed Name

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).


Use this form for each name, other than your genuine legal name, that you intend to use in conjunction with your insurance business.  If you have established a business entity and want to use the name of the business entity in conjunction with your insurance transactions, the business entity must also hold an insurance license. 

Priority: 
L0193
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

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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