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).
Must be completed by each partner, officer, and director, and each other entity owning 25% or more of a Service Company applicant.
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.
Complete this form to report the name and title of each individual reflected in the count on Form E-100, Item 13, Section E.
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).
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.