New version of form posted 03/18/2022 @ 11:15AM  Use this form to first determine whether you need to apply for a third-party administrator registration.  If the first page of the application indicates you must apply, complete the remainder of the application and include ALL required enclosures along with your fee payment.  An incomplete application will delay your registration and will create additional work for you and for us.  Submit your completed application, including all required enclosures and payment, using the Third Party (Life/Health) Administrator Registration Portal, accessible at https://azinsurance.online/Upload/tpa. 

To ensure your application is complete, correct, and meets all registration requirements so the Department can promptly issue a Certificate of Registration, use this document to check your application before you submit it.  The Department uses this document when reviewing applications.

Face amount must equal the greater of either (A) 10% of total funds handled for life and health coverage of Arizona residents, or (B) $5,000. Funds handled includes premiums collected for and/or claims paid on behalf of an insurer.  Submit with power of attorney. ARS § 20-485.10

All individuals applying for an Arizona-resident license and applicants who are non-resident adjusters from states that do not license adjusters must complete this form.

To make your application process faster and easier, use NIPR.COM and apply online instead of completing, printing and mailing this application

A business entity must report a change to the entity's owners, partners, officers, or directors within 30 calendar days of the change.  A business-entity bail bond agent must also furnish a fingerprint card and $22.00 for each new officer.

To make your renewal process faster and easier, use NIPR.COM and renew online instead of completing, printing and mailing this application.

To make your renewal process faster and easier, use NIPR.COM and renew online instead of completing, printing and mailing this application.

Form L-BBAA: Bail Bond Agent Affidavit of Residence

Each year, every bail bond agent must complete this report concerning bail recovery agents the bail bond agent employed, hired as independent contractors or otherwise used at any time during the previous calendar year.  The Insurance Licensing Section must receive the completed report by January 31.  ARS § 13-3885(D).

A bail recovery agent must complete this form and must include a clear 2" X 3" photograph of the bail recovery agent's face.

A bail bond agent notification to the Department of Insurance of using a bail recovery agent.

Licensees needing to update address, phone and e-mail information must use the NIPR Contact Change Request (www.nipr.com) instead of using this form.  

Use this form if:

A.  You are relocating to another state and need to provide a clearance letter from Arizona, OR

B.  You want to permanently surrender insurance license authority.  Be careful!  If you surrender insurance license authority, Arizona law prevents you from reapplying for the surrendered authority for one year. 

This form is to be used by individuals who are required to submit fingerprints as part of an insurance license application. The form includes detailed instructions that must be exactly followed for fingerprints to be accepted by the Department of Insurance and Financial Institutions.

Self Service Storage Agents and Rental Car Agents must specify all office locations from which the entity may transact insurance business.

Complete and file this form with the life settlement broker license fee within the first 30 days of operating as a life settlement broker. 

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. 

The document contains detailed instructions and forms to apply to become a navigator or certified application counselor. 

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.

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). 

Only use this form (rather than paying the license fee) if you meet all the requirements on the form.  If you file this form, it becomes part of your license application, and if you file incorrect, misleading, incomplete, or materially untrue information on a license application, an insurance license can be denied, suspended or revoked, you could be assessed civil penalties and you could be the subject of other administrative and legal consequences.  The fee waiver only applies to the license fee.  It does not apply to other fees and costs you may need to pay in order to become licensed.

Fees are nonrefundable upon payment.  ARS § 20-167(A)

Must be completed by each partner, officer, and director, and each other entity owning 25% or more of a Service Company applicant.

To make your application process faster and easier, use NIPR.COM and apply online instead of completing, printing and mailing this application