Form E126XS (v 20210326)
APPLICATION AND ORDER FOR RELEASE OF EXCESS DEPOSIT
A. Application (To be completed by Applicant)
(Name of Insurer) (NAIC#)
A (Domicile State) corporation, is filing this application as required by A.R.S. § 20-
588 for release of funds deposited with the Arizona State Treasurer, which total $
in par/face value.
I
certify, as a duly authorized officer, that such funds are in excess of the required deposit amount of
$ and that upon release, the remaining amount of funds on deposit,
measured as the lessor of $ in par/face value or $
in current market value, satisfy our deposit requirement.
Signed: Dated:
In my capacity as: (Title)
B. Order (To be completed by Department of Insurance and Financial Institutions)
By authority of the Director of Insurance and Financial Institutions delegated in accordance with A.R.S. §
20-148 and A.R.S. § 20-150, and in accordance with A.R.S. § 20-588, IT IS HEREBY ORDERED approvin
g
t
he application for release of excess deposit set forth above,
effective this day of , .
Kurt Regner, CFE
Assistant Director, Insurance Financial Affairs Division
Emailed this day of ,
by
