Form E-157 (v. 20180619)
Phone: (602) 364-3450
Attn: TPA Registration Team
Arizona Department of Insurance
100 North 15th Avenue, Suite 261
Phoenix, Arizona 85007-2630
Email: tpainformation@azinsurance.gov
BOND OF LIFE AND HEALTH ADMINISTRATOR
KNOW ALL MEN BY THESE PRESENTS, that we, , as
Principal and Applicant for a Life and Health Insurance Administrator's Certificate of Registration (hereinafter "the
Principal"), and , a
corporate surety authorized to transact business in the State of Arizona, as Surety, (hereinafter "the Surety"), are held and
firmly bound unto the State of Arizona, as Obligee, for the benefit and protection of insureds and insurers whose monies
the Principal handles in (his/her/its) capacity as Administrator, in the amount of $ , lawful
money of the United States of America, for the payment whereof, the said Principal and Surety bind themselves and their
heirs, administrators, executors, successors and assigns, jointly and severally, firmly by these presents.
WHEREAS, the Principal desires to act as an Insurance Administrator pursuant to the provisions of Title 20, Chapter 2,
Article 9 of the Arizona Revised Statutes; and
WHEREAS, Section 20-485.06 of said Article 9 stipulates that the Principal shall act in a fiduciary capacity while handling
charges, premiums, return premiums or any other funds belonging to others while performing his duties as administrator.
NOW, THEREFORE, the conditions of this obligation are such that if the said Principal shall faithfully perform (his/her/its)
duties as Administrator and fulfill all obligations imposed upon said Principal by the provisions of Title 20, Chapter 2,
Article 9, Arizona Revised Statutes, then this bond shall be void, otherwise to remain in full force and effect, subject to the
following conditions:
1. This bond, drawn and executed in the manner prescribed by A.R.S. §20-485.10 shall remain in force until released by
the Director of Insurance or until cancelled by the Surety. Without prejudice to the liability previously incurred
thereunder, the Surety may cancel, decrease or increase this bond only upon thirty (30) days advance written notice
filed with the Director of Insurance.
2. In the event the said Principal shall fail to pay any benefits (he/she/it) is legally obligated to pay, or an insured or
insurer shall suffer a loss by reason of acts of fraud or dishonesty, this bond shall immediately and automatically
become due.
3. The undersigned are jointly and severally held and firmly bound for the payment of all legal costs, including
reasonable attorneys' fees incurred in all or any actions or proceedings taken to enforce payment of this bond.
Signed this day of , .
Principal
By
Surety
Licensed Insurance Producer Attorney in Fact
POWER OF ATTORNEY MUST BE ATTACHED TO THIS BOND
