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.

Priority: 
NAIC011
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 E125: Security Deposit Form
Form E126: Security Release 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.

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 E-100: Application for Life and Health Administrator Registration

New version of form posted 06/26/2018 @ 3:14PM.  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

Form E-100-A: Life and Health Administrator Registration Addendum

If the applicant uses any name or has any office other than those reported in Section A or B of Form E-100, use this form to report the applicant's complete name and address for all offices in each jurisdiction.  ARS § 20-485.12(B)(6).

Form E-100-B: Life and Health Administrator Biographical List

Complete this form to report the name and title of each individual reflected in the count on Form E-100, Item 13, Section E.

Form E-111: Renewal Application for Life and Health Administrator Registration

Due Date:  March 1
You may submit your renewal application after January 1, but the renewal application must be received by the Department of Insurance by March 1 or you will be subject to a $25 per day late fee.  The application must be certified by two officers of the applicant.  Must be current within 90 days of application filing date. Use the TPA Online Registration Portal at https://azinsurance.online/Upload/tpa to file renewal documents and pay the renewal fee.  ARS § 20-485.12(B)(1)(a) and (b)

Form E-115: Life and Health (Third-party) Administrator Information Update

New version of form posted 06/26/2018 @ 3:20PM.  Complete this form to register NEW information that has changed since the TPA was last reported to the Arizona Department of Insurance (ADOI).  Use the Third-party Administrator Registration Portal at https://azinsurance.online/Upload/tpa to submit required documents to us.  It is critical that you update the information with the ACC before filing updated information with the ADOI.

Form E157: Bond of Life and Health Administrator

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

Form E-200: TPA Registration Application Checklist

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.

Form E-503-TPA: Affidavit of Lost Certificate of Registration

Complete this form if surrendering a Certificate of Registration that has been misplaced or destroyed.

Form L-152: Licensing Eligibility (Lawful Presence in the US) Requirement

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.

Form L-176: Insurance License Application for a Business Entity

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

Form L-177: Report of a Change to Members, Officers or Directors

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.

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