LICENSING-RELATED FORMS

This page presents a list of licensing-related forms.  We strongly recommend that before completing a form, you consult the menu option on our web site for the type of license you hold or wish to hold.

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-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 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 members, officers, directors or designated responsible producer 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-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-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-193: Certificate of Assumed Name

Use this form for each name, other than your genuine legal name, that you intend to use in conjunction with your insurance business.  If you have established a business entity and want to use the name of the business entity in conjunction with your insurance transactions, the business entity must also hold an insurance license. 

Form L-195: Bond of Bail Bond Agent

A bail bond agent must provide and maintain throughout the term of the license a $10,000 surety bond.

Form L-BBAA: Bail Bond Agent Affidavit of Residency

An applicant for a bail bond agent license must attest and affirm continuous residency in Arizona during the preceding one-year period.

Form L-BBAR: Bail Bond Agent Annual Report

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).

Form L-BFP: Bail Recovery Agent Fingerprint Submission

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

Form L-BRA: Notice of Bail Recovery Agent Utilization

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

Form L-CHG: License Information Change

Individuals needing to update address, phone and e-mail information must use the NIPR Contact Change Request (www.nipr.com) instead of using this form.  An individual may use this form to report a name change, and a business entity may use this form to report a change of Designated Producer, name, address, phone number or e-mail information.  

Form L-CLR: Clearance Letter Request

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. 

Form L-CRT: Certification Letter Request

Information concerning Arizona insurance licenses is available at no charge from the License Search menu option on our web site. Insurance companies and the public are encouraged this License Search feature (rather than a paper printout or a letter of certification) to verify the lines of authority, license issuance and expiration dates, and license status for an Arizona-licensed insurance professional.

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ARS § 41-1030(G) requires most Arizona government agencies to prominently print the provisions of ARS § 41-1030(B), (D), (E) and (F) on all license applications.  The following is the language in ARS § 41-1030(B), (D), (E) and (F):

B.        An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically authorized by statute, rule or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for imposing a licensing requirement or condition unless a rule is made pursuant to that general grant of authority that specifically authorizes the requirement or condition.

D.        This section may be enforced in a private civil action and relief may be awarded against the state.  The court may award reasonable attorney fees, damages and all fees associated with the license application to a party that prevails in an action against the state for a violation of this section.

E.        A state employee may not intentionally or knowingly violate this section.  A violation of this section is cause for disciplinary action or dismissal pursuant to the agency’s adopted personnel policy.

F.         This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.

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