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Title Last updated Attachments
Form E-AHCCCS: AHCCCS Contractor Quarterly Premium Tax Report 01/01/2021 (Tue)
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File E-ahcccs_20201231.xlsx69.71 KB
Form E-AFR.OHE: Audited Financial Report Organizational Hardship Exemption Guidelines and Sample Affidavit 05/11/2020 (Mon)
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PDF icon Audited Financial Report Organizational Hardship Exemption E-AFR-OHE web version.pdf4.48 MB
Form E-AFR.IC: Audited Financial Report Internal Control Filings Transmittal 11/11/2019 (Thu)
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PDF icon Audited Financial Report Internal Control Filings E-AFR.IC_.pdf4.45 MB
Form E-AFR.IC.RE: Audited Financial Report Internal Control Filings Transmittal Reinsurer 05/11/2020 (Mon)
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PDF icon Audited Financial Report Internal Control Filings E-AFR.IC_.RE web version.pdf4.31 MB
Form E-AFR.GFE: Audited Financial Report Exemption Guidelines 05/11/2020 (Mon)
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PDF icon Audited Financial Report Guidelines for Exemptions E-AFR-GFE web version.pdf4.46 MB
Form E-ACTOP: Actuarial Opinion Exemption Guidelines 10/02/2020 (Mon)
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PDF icon Actuarial Opinion Financial Hardship Exemption E-ACTOP.pdf4.57 MB
Form E-857: Bond of Service Company 10/02/2020 (Wed)
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PDF icon Form E-857 Bond of Service Company.pdf729.67 KB
Form E-820: Service Company Application Checklist 11/08/2018 (Tue)
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PDF icon Form E-820 Service Company Review Checklist817.73 KB
Form E-811: Renewal of Service Company Permit 10/02/2020 (Wed)
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PDF icon Form E-811 Service Company Renewal.pdf974.48 KB
Form E-801: Motor Vehicle Dealer's Notice of Intent 10/02/2020 (Wed)
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PDF icon Form E-801 Motor Vehicle Dealer's Notice of Intent.pdf770.74 KB
Form E-800: Application for Service Company Permit 10/02/2020 (Wed)
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PDF icon Form E-800 Service Company Application.pdf1.01 MB
Form E-800-B: Service Company Biographical List 10/02/2020 (Wed)
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PDF icon Form E-800-B Service Company Application Biographical List.pdf745.27 KB
Form E-711: Purchasing Group List of Insurers and Agents 10/02/2020 (Wed)
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PDF icon Form E-711 Purchasing Group List of Insurers and Agents.pdf656.58 KB
Form E-710: Application for Purchasing Group Registration 10/02/2020 (Wed)
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PDF icon Form E-710 Purchasing Group Application.pdf654.61 KB
Form E-701: Certificate of Public Supervisory Official 10/02/2020 (Wed)
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PDF icon Certificate of Public Supervisory Official Form E-701 (1).pdf1.49 MB
Form E-700: Certificate of Surplus Lines Broker 12/11/2020 (Thu)
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PDF icon Certificate of Surplus Lines Broker Form E-700 (1).pdf1.24 MB
Form E-654: Application for Life Care Provider Permit Change 04/11/2020 (Tue)
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PDF icon Life Care Provider Permit Change Application E-654.pdf807.44 KB
Form E-653: Checklist for Change from a Provisional Permit to Life Care Provider Permit 04/11/2020 (Tue)
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PDF icon AdmLifeCareE653.pdf133.7 KB
Form E-652: Application for Life Care Provider Permit 08/07/2018 (Thu)
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PDF icon Life Care Provider Permit Application E-652.pdf673.06 KB
Form E-651: Checklist for Application for Life Care Provider Permit 04/11/2020 (Tue)
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PDF icon AdmLifeCareE651.pdf134.47 KB
Form E-503-TPA: Affidavit of Lost Certificate of Registration 03/12/2018 (Tue)
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PDF icon Form E-503-TPA Affidavit of Lost Certificate of Registration.pdf983.69 KB
Form E-200: TPA Registration Application Checklist 02/12/2018 (Tue)
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PDF icon TPA Form E-200_20160721.pdf927.57 KB
Form E-178: Certificate of Disclosure 05/11/2020 (Mon)
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PDF icon Certificate of Disclosure E-178 web version.pdf1018.01 KB
Form E-115: Life and Health (Third-party) Administrator Information Update 02/12/2018 (Tue)
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PDF icon TPA Form E-1151.46 MB
Form E-111: Renewal Application for Life and Health Administrator Registration 02/12/2018 (Tue)
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PDF icon Form E-111 TPA Renewal Application.pdf1.41 MB
Form E-100: Application for Life and Health Administrator Registration 08/08/2019 (Mon)
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PDF icon Form E-100 TPA New Application 20190809.pdf1.72 MB
Form E-100-B: Life and Health Administrator Biographical List 02/12/2018 (Tue)
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PDF icon Form E-100-B TPA Biographical List.pdf767.11 KB
Form E-100-A: Life and Health Administrator Registration Addendum 02/12/2018 (Tue)
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PDF icon Form E-100-A TPA New Application Addendum.pdf762.14 KB
Form CU 1621: Credit Property/Credit Unemployment Certification of Rates 02/04/2019 (Mon)
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PDF icon CU 1621 Certification Form.pdf996.26 KB
Form C-TPC: Third-party Consent 09/05/2020 (Fri)
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PDF icon 3rd Party Consent2.pdf1.28 MB
Form C-RFI 10/02/2020 (Thu)
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PDF icon c-rfi_20200221.pdf1.38 MB
Form 1024B: Calculation of Company Loss Cost Multiplier 08/11/2014 (Fri)
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PDF icon CALCULATION_OF_COMPANY_LOSS_COST_MULTIPLIER_1024B_(Fillable).pdf70.68 KB
Form 1024A: Insurer Rate Service Organization Reference Filing Adoption Form 08/11/2014 (Fri)
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PDF icon REFERENCE_FILING_ADOPTION_FORM_1024A_(Fillable).pdf30.92 KB
Foreign Insurers 04/01/2020 (Thu)
FOREIGN INSURER: Unaffiliated Credit Life & Disability Reinsurer 06/01/2020 (Fri)
FOREIGN INSURER: Title Insurer 03/01/2019 (Fri)