Form E-503-TPA (v. 20181217)
Phone: (602) 364-3450
Attn: TPA Registration Team
Arizona Department of Insurance
Email: tpainformation@azinsurance.gov
AFFIDAVIT OF LOST CERTIFICATE OF REGISTRATION
)
State of )
) ss.
County of )
)
)
I, _______________________________________ (name of officer), being first duly sworn,
upon my oath depose and say:
1. I am the _________________________________________________ (title of officer) of
_______________________________________ (name of administrator) and am duly
authorized to execute this affidavit on its behalf.
2. After due and diligent search, the Certificate of Registration issued to
________________________________________________________ (name of administrator)
by the Arizona Department of Insurance effective ___________________________, ________
(date issued), cannot be found.
3. I recognize that a Certificate of Registration remains the property of the State of Arizona
and shall immediately deliver such Certificate of Registration to the Director of Insurance when
and if found.
Further affiant sayeth not.
(Signature of officer)
Subscribed and sworn to before me this ________ day of __________________, _____ .
(Signature of Notary Public)
My commission expires:
