Fillable Arizona Department of Insurance (Arizona)

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Arizona Department of Insurance (Arizona)

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Licensing Section
Arizona Department of Insurance
100 North 15
th
Avenue, Suite 102, Phoenix, Arizona 85007-2624
Phone: (602) 364-4457 | Toll-free: (877) 660-0964
Web: https://insurance.az.gov | E-mail: Licensing@azinsurance.gov
Form L-FPV (Rev. 20180618)
Arizona Department of Insurance
FINGERPRINT VERIFICATION FORM (FORM L-FPV)
READ ALL INSTRUCTIONS. If you do not carefully follow these procedures, the Arizona Department of
Insurance (“ADOI”) will reject the fingerprint card.
1. Please fill out or ensure that the applicant has filled out all required boxes on the fingerprint card
(Form FD-258) prior to taking the fingerprints.
2. Request a valid, unexpired, government-issued photo ID from the applicant and compare the physical
descriptors on the ID to the applicant and to the information on the fingerprint card.
3. Complete the following information:
Applicant’s Last Name
Applicant’s First Name
Applicant’s Middle Name
PRINTED Name of Fingerprint Technician
Fingerprint Technician’s Business/Entity/Organization Name:
Fingerprint Technician’s Signature
X ________________________________________________________________
Phone No.
Type of Photo Identification Checked (select only one)
Driver License or MVD-issued Identification US Passport or US Passport Card
Other (specify)
___________________________________________________________________________________
4. Once the fingerprints have been applied to the card, you must:
Place the fingerprint card and this form into an envelope and seal it. Any envelope that fits the card is
acceptable;
Print your name across the edge of the sealed area of the envelope.
DO NOT GIVE THE APPLICANT THE FINGERPRINT CARD WITHOUT FIRST SEALING IT
INSIDE THE ENVELOPE.
5. Tell the applicant NOT to open or fold the fingerprint card envelope, which would cause the card to be
rejected.
QUESTIONS?
Regarding a fingerprint card for an insurance professional license applicant (producer,
adjuster, bail bond agent etc.),
contact the Insurance Licensing Section: licensing@azinsurance.gov
or (602) 364-4457
Regarding a fingerprint card for an Arizona domiciled insurance company
representative,
contact the Financial Affairs Division: amccormack@azinsurance.gov or (602) 364-3245
?
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Arizona Department of Insurance (Arizona)

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Completed 12 August 2020

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