Form P-LSA: Life Settlement Provider/Broker Disclosures to Owner; Affiliations

NEW ADDRESS


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

Phoenix, AZ  85007-2630

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

This document has been approved by the Department of Insurance and it does not need to be filed with the Department by a broker or provider. Use this form in conjunction with Form P-LSDO. A provider or broker who intends to use a different form must submit the form for approval using the NAIC System for Rate and Form Filings ("SERFF"), accessible at http://www.serff.org.