NAIC uniform license application for an Individual

NEW AGENCY


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).


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

Priority: 
LI10000
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Form L-192: License Renewal Application for a Business Entity

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

Form L-191: License Renewal Application for an Individual

To make your renewal process faster and easier, use NIPR.COM and renew 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.

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-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 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-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 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-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).

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