LICENSING-RELATED FORMS

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).


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 L-FPV: Fingerprint Verification

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.

Form L-LOC: Branch Locations

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

Form L-LSB: Life Settlement Broker Application

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

Form L-LTD: Limited License Authority Application

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. 

Form L-NAV: Application for Navigator or Certified Application Counselor License

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

Form L-PFD: Petition for Determination

You can use this form to ask the Department of Insurance to determine whether a criminal conviction disqualifies you for a license.  

Form L-SURR: License Surrender Request

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.

Form L-TEMP: Application for a Temporary Insurance License

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). 
NAIC uniform license application for an Individual

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

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.

Form RO31010: License Application for a Rating Organization
Form RSO31010: License Application for a Rate Service Organization

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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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