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Arizona Department of Insurance
100 North 15th Avenue, Suite 261

Phoenix, AZ  85007-2630

Starting July 1, 2020, we will be the
Department of Insurance and Financial Institutions (DIFI).

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Titlesort descending Last updated Attachments
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-178: Certificate of Disclosure 11/02/2020 (Mon)
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PDF icon Certificate of Disclosure E-178.pdf748.82 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-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-651: Checklist for Application for Life Care Provider Permit 02/06/2018 (Tue)
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PDF icon AdmLifeCareE651.pdf52.06 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-653: Checklist for Change from a Provisional Permit to Life Care Provider Permit 02/06/2018 (Tue)
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PDF icon Form E-65354.28 KB
Form E-654: Application for Life Care Provider Permit Change 08/07/2018 (Thu)
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PDF icon Life Care Provider Permit Change E-654.pdf646.21 KB
Form E-700: Certificate of Surplus Lines Broker 10/02/2020 (Wed)
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PDF icon Certificate of Surplus Lines Broker Form E-700 (1).pdf1.24 MB
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-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-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-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-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-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-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-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-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-ACTOP: Actuarial Opinion Exemption Guidelines 10/02/2020 (Mon)
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PDF icon Actuarial Opinion Financial Hardship Exemption E-ACTOP.pdf769.5 KB
Form E-AFR.GFE: Audited Financial Report Exemption Guidelines 10/02/2020 (Mon)
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PDF icon Audited Financial Report Guidelines for Exemptions E-AFR-GFE (2).pdf3.91 MB
Form E-AFR.IC.RE: Audited Financial Report Internal Control Filings Transmittal Reinsurer 10/02/2020 (Mon)
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PDF icon Audited Financial Report Internal Control Filings E-AFR.IC_.RE (2).pdf1.01 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_.pdf1.35 MB
Form E-AFR.OHE: Audited Financial Report Organizational Hardship Exemption Guidelines and Sample Affidavit 10/02/2020 (Mon)
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PDF icon Audited Financial Report Organizational Hardship Exemption E-AFR-OHE (1).pdf170.38 KB
Form E-AHCCCS: AHCCCS Contractor Quarterly Premium Tax Report 03/01/2020 (Fri)
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File e-ahcccs_20200131.xlsx56.77 KB
Form E-AMEND: Summary to Changes to Taxes and Fees 12/01/2018 (Sat)
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File e-amend.xlsx69.07 KB
Form E-AR-1: Certificate of Assuming Insurer 08/07/2018 (Thu)
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PDF icon Reinsurer E-AR-1 Certificate of Assuming Insurer.pdf1.49 MB
Form E-CERTREQ: Certificate Request Form 11/01/2020 (Wed)
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PDF icon Certificate Request Form 20200110.pdf857.94 KB
Form E-CR-1: Certificate of Certified Reinsurer 08/07/2018 (Thu)
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PDF icon Certified Reinsurer E-CR-1 Certificate.pdf1.84 MB
Form E-CR-C: Uniform Application Checklist for Certified Reinsurers 09/07/2018 (Fri)
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PDF icon Certified Reinsurer E-CR-C Application Checklist.pdf1.24 MB
Form E-CR-F Instructions 03/06/2018 (Tue)
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PDF icon Form E-CR-F51.96 KB
Form E-CR-I: Certified Reinsurer Instructions 02/06/2018 (Tue)
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PDF icon Certified Reinsurer CR-I Instructions.pdf57.17 KB
Form E-CR-INFO: Certified Reinsurer Information 10/02/2020 (Mon)
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PDF icon Certified Reinsurer E-CR-INFO Information 20200220.pdf160.24 KB
Form E-CR-S Instructions 03/06/2018 (Tue)
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PDF icon Form E-CR-S Instructions56.67 KB
FORM E-DIRCOMWAIVER: Arizona Domestic Insurers Board of Directors and/or Committees Waiver Application 08/07/2018 (Thu)
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PDF icon Holding Company Directors Committees Waiver E-DIRCOMWAIVER.pdf58.58 KB
Form E-FBS: Annual Fees and Retaliation Report for a Fraternal Benefit Society 05/01/2020 (Fri)
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PDF icon Form E-FBS (v. 20200131)896.35 KB
Form E-HCSO.13: Certificate of Advertising Compliance 10/02/2020 (Mon)
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PDF icon Certificate of Advertising Compliance E-HCSO.13.pdf659.24 KB

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