Arizona Department of Insurance
100 North 15th Avenue, Suite 261Phoenix, AZ 85007-2630
Starting July 1, 2020, we will be the
Department of Insurance and Financial Institutions (DIFI).
An Arizona-authorized domestic insurer uses this application form to apply to be designated as a domestic surplus lines insurer.
For unauthorized foreign/alien insurer qualification: The surplus lines broker must complete and sign this form and provide this form with other surplus lines insurer sponsorship forms to the Department of Insurance Surplus Lines Team. REPLACES FORM SL-110.
For unauthorized foreign/alien insurer qualification: The public supervisory official from the insurer's domicile must complete this form and return the form to the surplus lines broker. The broker must submit the completed form with other surplus lines insurer sponsorship forms. REPLACES FORM SL-111.
Surplus lines brokers must place business with an Arizona-authorized insurer when insurance is procurable from an authorized insurer. When insurance is not procurable from an authorized insurer, a surplus lines broker may procure coverage from a Domestic Surplus Lines Insurer, from an insurer on Arizona's List of Qualified Unauthorized Surplus Line Insurers, or from an insurer on the NAIC Quarterly Listing of Alien Insurers.