SeptemberϯϬ,2014  1|Page
Becoming a Navigator or
Certified Application Counselor
A. General Requirements
HouseBill2508createdARS§20336etseq.,whichprovidesrequirementsforhealthinsurance
exchangenavigatorsandcertifiedapplicationcounselors(“CACs”).
AFTERYOUSATISFYFEDERALTRAININGANDCERTIFICATIONREQUIREMENTS,youcanactasa
navigatororCACinArizonaonorafterOctober1,2014,ifyousatisfyoneofthefollowingthree
requirements:
1. YouarelicensedasanavigatororCAC,respectively;or
2. YouholdanArizonaaccidentandhealthorsicknessinsuranceproducerlicense;or
3. Youworkonlyontriballandsandyouunderwentafederalservicesecuritybackground
investigation.
HouseBill2508takeseffectJuly24,2014,whichmeansthattheInsuranceLicensingSection
willbegintoreviewapplicationsfromandafterthatdate.Inthemeantime,individualsand
businessentitiescancompletethenecessarystepstoqualifyfortheArizonalicense.
B. Arizona License Requirements for Individuals
TobeanindividuallicensedasanavigatororCAC,youmustfulfillallthefollowing
requirements:
Beatleast18yearsold.
HavenotcommittedanyactionthatisagroundforlicensedenialunderARS§20295.
Havenotbeenconvictedofamisdemeanorinvolvingfraudordishonesty
.
FulfillandmaintainHealthInsuranceMarketplace(“HIM”)navigatororCACcertification
requirements.
o Reviewandstudytrainingmaterials(see
http://marketplace.cms.gov/training/gettraining.html).
o CreateaHealthInsuranceMarketplacetraining/certificationaccountat
https://marketplace.medicarelearningnetworklms.com/Default.aspx(usingthe
“CreateAccount”linkifyoudonotalreadyhaveone)andentering
“Marketplace”astheorganizationoremployer.
SeptemberϯϬ,2014| BecomingaNavigatororCAC 2|Page
o Completetheonlinetrainingcourses,passallcourseexaminationsandreceive
yournavigatororCACcertification.
SubmittotheInsuranceLicensingSectionthefollowing:
o ompletedlicenseĞůŝŐŝďůŝůŝƚLJ;&Žƌŵ>ͲϭϱϮͿapplication;&Žƌŵ>ͲEsͿĨŽƌŵƐ͕
ĂǀĂŝůĂďůĞĨƌŽŵƚŚĞĞƉĂƌƚŵĞŶƚΖƐΗƉƉůLJŝŶŐŽŶWĂƉĞƌΗǁĞďƉĂŐĞ
(http://www.azinsurance.gov/producers/prod_get_apply_paper.html).
o EvidenceofyourfederalnavigatororCACcertification.
o Ifyouunderwentacriminalhistoryrecordscheckasaconditionofemployment
asanavigatororCACbetweenAugust1,2010,andJuly24,2014,completeyour
portionofFormLCRHandhaveyouremployercompletetheirportion,attesting
toyourhavi ng passedthecriminalhistoryrecordscheck.FormLCRHisprovided
aspartoftheFormLNAVapplicationpacket.
o Ifyoudidnotundergoacriminalhistoryrecordscheckasaconditionof
employmentasanavigatororCACbetweenAugust1,2010,andJuly24,2014,
fingerprintssealedinanenvelopewithaFormLFPVcompletedbythe
fingerprintcardtechnicianinaccordancewithinstructionsprovidedontheform
accompaniedbyafingerprintcardprocessingfee(currently$22foreachcard).
Thefingerprintswillbeusedforacriminalhistoryrecordsoftheapplicant.Form
LFPVisprovidedaspartoftheFormLNAVapplicationpacket.
BeaffiliatedwithandsupervisedbyabusinessentitynavigatororCAC.
Fulfillongoing(annual)federaltraining/recertificationrequirements.
C. Arizona License Requirements for Business Entities
Tobelicensedasabusinessentitynavigator(Arizonalawdoesnotprovideforbusinessentity
CACs),thebusinessentitymustmeetallthefollowingrequirements:
Thebusinessentityshallnothavecommittedanyactthatisgroundforlicensedenial
underARS§20295.
Thebusinessentityhasnotbeenconvictedofamisdemeanorinvolvingfraudor
dishonesty.
Thebusiness
entitysubmitstotheInsuranceLicensingSectionthefollowing:
DirectquestionsconcerningHealthInsuranceMarketplace
registration,trainingorcertificationtotheCentersfor
Medicare&MedicaidServices(CMS).
SeptemberϯϬ,2014|BecomingaNavigatororCAC 3|Page
o Acompletedlicenseapplication(FormLNAV),currentlyavailablefromthe
Department’s“ApplyingonPaper”webpage
(http://www.azinsurance.gov/producers/prod_get_apply_paper.html).
o Foreachbusinessentityboardmember,officerordirector(e.g.theindividuals
reportedtotheArizonaCorporationCommissionorArizonaSecretaryofStatein
formationdocuments),fingerprintssealedinanenvelopewithaFormLFPV
completedbythefingerprintcardtechnicianinaccordancewithinstructions
providedontheformaccompaniedbyafingerprintcardprocessingfee
(currently$22foreachcard).Thefingerprintswillbeusedforacriminalhistory
recordsofthememb
ers,officersanddirectors.FormLFPVisprovidedaspart
oftheFormLNAVapplicationpacket.
Thebusinessentityhasdesignated(andreportsonFormLNAV)anindividuallylicensed
navigatorwhoisresponsibleforthebusinessentity’scompliancewithArizonainsurance
laws.
D. License Term
IfthenavigatororCACapplicantalreadyholdsanArizonainsurancelicense,thetermofthe
navigatororCACauthoritywillexpireatthesametimeasexistinglicenseauthority.
IftheapplicantdoesnotalreadyholdanArizonainsurancelicense,
Thelicenseofanindividualshallexpireonthelastdayofthemonthoftheindividual’s
birth,atleastthreebutnotmore
thanfouryearsafterthedateoflicensure.
Thelicenseofabusinessentityshallexpireonthelastdayofthe month,fouryearsafter
thedatethelicenseisissued.
HOWEVER,navigatorsandCACsmustalsomeetannualfederaltrainingandrecertification
requirements.
BecauseabusinessentitymustidentifyanArizonalicensed
navigatortoserveasitsdesignatedresponsibleindividual,and
becauseanindividualnavigatormustreportthebusinessentity
withwhichthenavigatorisaffiliated,theLNAVforthe
designatedresponsibleindividualshouldbesubmittedatthe
sametimeastheLNAVforthebusi
nessentity,witheach
applicantreferencingtheother.
SeptemberϯϬ,2014|AccessingFederalMarketplaceResources 4|Page
Accessing Federal Marketplace
Resources for Navigators and
Certified Application Counselors
Go to the Health Insurance Marketplace “For Partners” page
1. Navigatetowww.healthcare.gov
2. Scrolldownandclickon“ForPartners”
SeptemberϯϬ,2014|AccessingFederalMarketplaceResources 5|Page
Become familiar with “Resources for assisters”
Theresourcesforassisterspageprovidesaconsiderableamountofinformationthatcanhelp
youassistconsumersthatmayfindthemselvesinunusualcircumstancesorthathave
specializedneeds.Themoreknowledgeableyoubecomewiththecontentoftheseresources,
themoreefficientlyandcomprehensivelyyouwillbeabletorenderassistance.
Go to “Get training”
AlthoughapplicantsfornavigatorandCACcertificationwillneedtocompletetrainingandpass
examinationsonline,theHealthInsuranceMarketplaceprovidesnavigatorandCACtraining
withindocumentsthatyoucandownloadtoyourcomputer.Youmaywishtostudythese
documentsofflinebeforelaunchingonlinetraining.
Thegettrainingpagealsoprovidessomebasicinformationforanyonewantingtogainbasic
familiaritywithhealthinsurance,theHealthInsuranceMarketplace,thesmallemployerhealth
optionsplan(SHOP),taxcreditsandothersubjects.
SeptemberϯϬ, 2014|AccessingFederalMarketplaceResources 6|Page
Use “official resources”
Thegetofficialresourcespagecontainseven
moreresources.Ofparticularinterestmaybe
thepublicationspage,whichcontainsHealth
InsuranceMarketplaceapplicationsfor
insuranceandcorrespondinginstructions,
appealformsandfactsheets),articlestohelp
consumersgetthemostfromthe
Marketplaceandotherresources.
Asyoucansee,thepagealsoallowsyouto
accesswidgetsandbadgesthatcanbeused
onInternetwebsites;graphicsthatcanbe
usedinconjunctionwithHealthInsurance
Marketplacemarketing;and,again,other
resources.The“Getgraphics”pageprovides
aHealthInsuranceMarketplace“branding
guide”thatshouldbeobserved.
Form L-NAV-Instructions (v. 20140930): Page 1 of 2
INSTRUCTIONS FOR FORM L-NAV
Carefully read these instructions and review your three-page application before submitting it. The instructions
describe additional forms or documents that you may need to submit with your application. If your application is
incomplete, the application will be rejected.
Clearly print in ink or type all information and sign the appropriate “AFFIDAVIT” in ink.
QUESTIONS? Before calling the Department of Insurance, please see if you can find the answer to your question on
the PRODUCERS page of the Department of Insurance Internet web site: http://www.azinsurance.gov/producers
For questions that are not addressed on our Internet web site, contact the Insurance Licensing Section:
E-mail: Licensing@azinsurance.gov
Phone: 602-364-4457, or 877-660-0964 if calling long-distance within Arizona.
Retain these instructions for your records. Do not submit these instructions with your application.
Submit your application materials and fees to the Insurance Licensing Section (Paragraph D, below)
A. Fees. You must pay a $22 NON-REFUNDABLE fingerprint processing fee for each fingerprint card you submit.
Include your payment made to INSURANCE LICENSING SECTION with your license application. The fingerprint
processing fee amount is subject to change. Check the PRODUCERS page of the Department of Insurance web
site for up-to-date fee information.
B. Form L-152. You must submit Form L-152 and a legible photocopy of both sides of one of the required forms of
identification as part of your L-NAV application.
C. Fingerprints. An individual who passed a criminal history check between August 1, 2010, and July 24, 2014, as
a condition of employment as a navigator or CAC may complete Form L-CRH instead of submitting fingerprints.
A fee is not required with Form L-CRH.
Each other individual applicant, and each business-entity member, officer, director (principal, trustee, etc.) must
correctly complete the following procedure to submit a completed fingerprint card (blue-outlined FBI Form
FD-258) with the fingerprint processing fee:
1. We strongly recommend you use a professional fingerprinting service that applies scans your fingerprints with
LiveScan technology and prints your fingerprints on a fingerprint card. LiveScan equipment typically provides
more legible fingerprints. Fingerprints that are illegible will be rejected and a replacement fingerprint card will
need to be submitted.
2. The fingerprinting technician must carefully follow instructions on Form L-FPV (Fingerprint Verification Form),
which will require you to show a valid, unexpired government-issued photo ID. Information on your ID must
be current and must match the information entered on the fingerprint card.
3. The fingerprinting technician will place the completed card and Form L-FPV in a sealed envelope and will
write his/her name along the envelope seal. DO NOT open or fold the envelope containing the card or the
card will be rejected.
4. Send or deliver to the Insurance Licensing Section the unopened and not-folded fingerprint card envelope
with the fingerprint card processing fee and other license application materials in a larger envelope.
Form L-NAV-Instructions (v. 20140930): Page 2 of 2
D. Organizational Documents (business entities only):
If the business entity is organized outside Arizona, the documents from the domiciliary state must show an
Arizona address as the entity’s principal location. ARS 20-281(4)(b).
If the applicant is a corporation or limited liability company, include a copy of the articles of incorporation
or articles of organization. The articles must show the primary business address as being within Arizona.
If the applicant is a partnership, include a copy of the written partnership agreement and certificate of
registration stamped as “recorded” in the office of the Arizona Secretary of State, or if organized outside
Arizona, stamped as “recorded” with the official office in which the partnership was recorded. The agreement
must show the primary business address as being within Arizona.
If the applicant is a business trust, include a copy of the filed and recorded trust agreement.
E. Send or deliver the completed application materials with any required fee to:
INSURANCE LICENSING SECTION, 2910 North 44th Street # 210, Phoenix, AZ 85018-7269
THE ARIZONA DEPARTMENT OF INSURANCE IS AN EQUAL EMPLOYMENT OPPORTUNITY AGENCY THAT
COMPLIES WITH THE AMERICANS WITH DISABILITIES ACT ("ADA') OF 1990. PERSONS WITH DISABILITIES MAY
REQUEST ACCOMMODATION BY CONTACTING THE ADA COORDINATOR AT 602-364-3471. REQUESTS SHOULD
BE MADE AS EARLY AS POSSILE TO ALLOW TIME FOR THE DEPARTMENT TO MAKE APPROPRIATE
ARRANGEMENTS.
If you submit fingerprints pursuant to this application, your fingerprints will be used to check FBI
criminal history records.
If you have a criminal history record, the Department of Insurance shall provide you the opportunity to
complete or challenge the accuracy of the information in the record, and a reasonable amount of time to
correct or complete the record (or decline to do so) before a license is denied based on the criminal
history record. The procedures for changing, correcting or updating your FBI criminal history record are
set forth in Title 28, Code of Federal Regulations (CFR), Sections 16.30 through 16.34. You can find
information on how to review and challenge your FBI criminal history record on the FBI Web site, at
www.fbi.gov under Criminal History Summary Checks, or by calling (304) 625-5590.
To obtain a copy of your Arizona criminal history record in order to review/update/correct the record, you
can contact the Arizona Department of Public Safety (ADPS) Criminal History Records Unit at (602)
223-2222. Information concerning the DPS review and challenge process is available on the ADPS
Web site, at www.dps.gov.
Form L-NAV (v. 201404): Page 1 of 3
APPLICATION FOR A NAVIGATOR LICENSE (FORM L-NAV)
1. READ THE ENCLOSED INSTRUCTION PAGES. INCOMPLETE APPLICATIONS WILL BE RETURNED.
2. Complete ALL PAGES of this form and fulfill all requirements described in the instructions. Forms are available on
the PRODUCERS page of our Internet web site (www.azinsurance.gov/producers).
3. Send your completed application materials with any required payment to:
INSURANCE LICENSING SECTION, 2910 North 44
th
Street, Suite 210, Phoenix, AZ 85018-7269
SECTION I: APPLICANT INFORMATION
Applicant is applying for: (please select one): Navigator Certified Application Counselor (CAC)
Applicant is (please select one):
a business entity (navigators only) an individual (navigator or CAC)
If a business entity - Full (genuine) name of business entity
If an individual - Last name First name Middle name Gender
Male Female
Date of birth
*To use a name other than your legal name, you must file an Assumed Name Certificate – see INSTRUCTIONS.
Principal business street address (may not be P.O. box)
City State ZIP code
Mailing address (optional)
City State ZIP code
Residence address (if an individual)
City State ZIP code
Business phone #
Home phone # (individual)
Fax number (optional)
Taxpayer ID (FEIN or Soc. Sec. #):
E-mail address (optional)
SECTION II: AFFILIATION WITH BUSINESS ENTITY (INDIVIDUALS ONLY)
List the name of the licensed entity that you are affiliated with and that will be providing supervision.
Business entity name:
Arizona license # (navigator only):
SECTION III: PRINCIPALS & DESIGNATED RESPONSIBLE LICENSEE (BUSINESSENTIT<1$9,*$7256 ONLY)
On the first row, enter the name of the individual licensed as a navigator who will be responsible for the entity’s compliance with
Arizona insurance laws. On the remaining rows, list the names and titles of all directors and officers of a corporation, partners if
a partnership, members and managers if a limited liability company, trustees if a trust, etc. Attach a signed and dated list if
additional space is needed. See “Fingerprinting Requirements” in the INSTRUCTIONS, Paragraph B.
Name: Title: Designated Responsible Licensee
Name: Title:
Name: Title:
Name: Title:
Name: Title:
Name: Title:
SPACE BELOW IS FOR INSURANCE DEPARTMENT USE ONLY
License Number: ________________
Approved for Licensing by: _______
66: Fingerprint ($22.00)
X Quantity ______
TF#:___________________
PDB Checked
Form L-NAV (v. 201404): Page 2 of 3
3
SECTION IV: TRAINING REQUIREMENTS
Include a copy of your Navigator or CAC training certificate that shows successful completion of training.
SECTION V: ADDITIONAL INFORMATION
ALL applicants must complete this section. Carefully read and respond to each of the following questions. You should
provide a “YES” answer even if you believe an incident has been cleared from your record. Willful misrepresentation of any
fact required to be disclosed in any application or accompanying statement is a violation of law and a ground to deny your
application.
For the purposes of this application, "convicted" includes, but is not limited to, having been found guilty by judge or jury or pled
guilty or no contest to any felony charge. A "No" response is incorrect if applicant has had any conviction dismissed,
expunged, pardoned, appealed, set aside or reversed, or had its civil rights restored, had a plea withdrawn or has been given
probation, a suspended sentence or a fine, or successfully completed a diversion program.
A Has the applicant EVER had any professional, vocational, business license or certification refused,
denied, suspended, revoked or restricted, or a fine imposed by any public authority?
Yes No
B. Has the applicant EVER withdrawn an application for a license or certification to avoid its denial, or have
you EVER surrendered a license or certification to avoid disciplinary action?
Yes No
C. Has the applicant EVER been found guilty of, have you had a judgment made against you for, or have you admitted to, any
of the following:
1. A felony (of any kind)? ............................................................................................................................
2. Obtaining or attempting to obtain any type of license through misrepresentation or fraud? .................
3. Forging another's name to any document related to an insurance transaction? ...................................
4. Withholding, misappropriating, converting or stealing money or property? ...........................................
5. Committing an insurance unfair trade practice or fraud? .......................................................................
6. Using fraudulent, coercive or dishonest business practices including forgery with intent to defraud? ..
7. Conducting business in an incompetent, untrustworthy or financially irresponsible manner? ...............
8. Transacting, or helping someone else transact, insurance without the required license authority? ......
9. Intentionally misrepresenting the terms of an actual or proposed insurance contract or application for
insurance? ..............................................................................................................................................
10. Any misdemeanor involving fraud or dishonesty ...................................................................................
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
D. Is any case currently pending against the applicant in any jurisdiction accusing you of any issue listed in
Question C?: .................................................................................................................................................
Yes No
If you answered “YES” to any question in Section V, you must submit:
1. A SIGNED statement describing in detail all incidents including
a. names of all parties involved,
b. dates and locations,
c. the names and localities of any courts and/or administrative agencies involved,
d. the disposition of each matter,
e. whether the conviction, plea or finding was for a felony or open-ended charge;
AND
2. Certified copies of any and all indictments, complaints, plea agreements, orders of conviction, notices of hearing or trial,
sentencing orders, suspension/revocation orders and any other information which relates to each matter. If certified copies
are not available, you must provide as a part of this application a letter from the clerk of the pertinent court or the official
involved stating the records are not available and the reason.
NOTE: The Violent Crime Control and Law Enforcement Act of 1994 prohibits any person convicted of any criminal
felony involving dishonesty, breach of trust or a violation of the Act from engaging in the business of insurance
without the specific written consent of the appropriate state insurance regulatory official. 18 U.S.C. 1033. A person
who does not obtain the specific written consent may be subject to federal criminal prosecution. There is no
automatic waiver for an individual who may already possess a license. Further, the Act prohibits any person or entity
from willfully permitting a prohibited person, as described above, from engaging in the business of insurance and the
Act subjects such a person or entity to criminal sanctions.
Form L-NAV-Instructions (v. 201404): Page 1 of 2
SECTION VI: AUTHORIZATION AND RELEASE
A business entity applicant must complete Subsection A; an individual applicant must complete Subsection B
SUBSECTION A: AFFIDAVIT OF VERIFICATION FOR A BUSINESS ENTITY
(Must be signed by an officer of the applicant)
By my signature below, I hereby attest and affirm all the following:
o Authorizes the Arizona Department of Insurance (“DEPARTMENT”) to conduct a background investigation to
determine the applicant’s fitness for an insurance license.
o Agrees to promptly respond to questions that may arise from the investigation.
o Authorizes and requests every person, firm, company, corporation, governmental agency, court, association or
institution having control of any documents, records and other information about person’s named in the application to
furnish to the DEPARTMENT any such information, and permits the DEPARTMENT, its employees, agents or
representatives, and the applicant’s authorized insurers, to inspect and make copies of such documents, records and
other information.
o Releases, discharges and exonerates the DEPARTMENT, its employees, agents and representatives, the State of
Arizona, the applicant’s authorized insurers, and any person furnishing information pursuant to this Authorization and
Release from any and all liability that may arise from any investigation made by the DEPARTMENT.
o Attests that the foregoing has been read and is understood.
o Certifies, to the best of his/her knowledge and belief and under penalty of denial, suspension or revocation of the
license or any other penalties that may apply, that the answers, statements and information furnished in connection
with this license application are true, correct and complete.
Signature of an officer of the applicant:
_______________________________
Printed or typed name of signer:
______________________________________
Date:
_________________
Telephone number:
(________) _____________________
Email address:
____________________________________________________________
SUBSECTION B: AFFIDAVIT OF VERIFICATION FOR AN INDIVIDUAL
By my signature below, I hereby attest and affirm all the following:
o You authorize the Arizona Department of Insurance (“DEPARTMENT”) to conduct a background investigation to
determine your fitness for an insurance license. You agree to promptly respond to questions that may arise from the
investigation.
o You authorize and request every person, firm, company, corporation, governmental agency, court, association or
institution having control of any documents, records and other information about you to furnish the DEPARTMENT
with any such information and you permit the DEPARTMENT, its employees, agents or representatives, and your
authorized insurers, to inspect and make copies of such documents, records and other information.
o You release, discharge and exonerate the DEPARTMENT, its employees, agents and representatives, the State of
Arizona, your authorized insurers, and any person furnishing information pursuant to this Authorization and Release
from any and all liability that may arise from the investigation made by the DEPARTMENT.
o You attest that you have read and understand the foregoing. You certify, under penalty of denial, suspension or
revocation of the license and under any other penalties that may apply that the answers, statements and information
furnished in connection with this license application are true, correct and complete to the best of your knowledge and
belief.
Signature of the applicant: Date:
___________________________________________________________________ ______________
Form L-152 (Eff. 01/2013)
ARIZONA DEPARTMENT OF INSURANCE
2910 NORTH 44TH STREET, SUITE 210
PHOENIX, ARIZONA 85018-7269
LICENSING ELIGIBILITY REQUIREMENT (ARS § 41-1080)
NOTE: This is NOT a license or renewal application form. You must complete all license
application or renewal application requirements IN ADDITION to completing this form.
Arizona Insurance License # (if
already licensed):
Last First Middle
Business Address (as shown
on license or application):
City, State and ZIP code
Arizona Revised Statutes § 41-1080 prevents a state agency from issuing a (new or renewed) license
to an individual unless the individual has provided the agency with one of the forms of identification
listed in the law. View additional information about this requirement on the PRODUCERS page of the
Department of Insurance Web site (www.azinsurance.gov).
To become or remain eligible for a license, complete this form, staple a photocopy showing both sides
of your identification to the back and return to the address in our letterhead (top). Only provide one
of
the following forms of identification (mark an “X” next to the one you are submitting):
1. An Arizona driver license issued after 1996 or an Arizona non-operating identification license.
2. A driver license issued by a state that verifies lawful presence in the United States. (Licenses
from HI, IL, ME, NM, UT, and WA are not acceptable)
3. A birth certificate or delayed birth certificate issued by any state, territory or possession of the
United States.
4. A United States certificate of birth abroad.
5. A United States passport.
6. A foreign passport with a United States visa.
7. An I-94 form with a photograph.
8. A United States citizenship and immigration services employment authorization document or
refugee travel document.
9. A United States certificate of naturalization.
10. A United States certificate of citizenship.
11. A tribal certificate of Indian blood.
12. A tribal or bureau of Indian affairs affidavit of birth.
By my signature below, I hereby certify, under penalty of perjury that the copy of the document I am
providing is a true and accurate copy of the original document and that I am legally authorized to be
present in the United States.
FULL SIGNATURE OF LICENSEE DATE
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. Complete, or ensure the applicant has completed, all required boxes on the fingerprint card (blue-outlined Form FD-
258) prior to applying fingerprints to the card. DO NOT USE HILIGHTERS OR MAKE STRAY MARKS ON THE
FINGERPRINT CARD.
2. View the applicant’s valid, unexpired government-issued photo ID. Make sure the photo resembles the applicant, and
compare the physical descriptors on the ID (hair color, eye color, etc.) to the information the applicant provided for the
fingerprint card. If the applicant’s ID does not match information the applicant provided for the fingerprint card, you
must refuse to apply fingerprints to the card.
3. Complete the following information
Applicant’s Last Name Applicant’s First Name Applicant’s Middle Name Jr/Sr/II/etc.
PRINTED Name of Fingerprint Technician Fingerprint Technician’s Business/Entity/Organization Name:
Street Address of Location Where Fingerprints Were Applied
City State ZIP Code
Area Code and Phone No.
Type of Photo Identification Checked (select only one)
Driver License or MVD-issued Identification
US Passport or US Passport Card
Other (specify) ___________________________________________________________________________________
Fingerprint Technician’s Signature
X ________________________________________________________________
Date
4. Once the fingerprints have been applied to the card, you must: place the fingerprint card and this form into a
fingerprint card envelope and seal the flap of the envelope; AND, print your name across the edge of the flap so
that the upper parts of the letters in your name are on the flap and the lower parts of the letters in your name are off of
the flap. YOU MUST 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,
contact the Insurance Licensing Section: licensing@azinsurance.gov or (602) 364-4457
Regarding a fingerprint card for an insurance company representative,
contact the Financial Affairs Division: lhunt@azinsurance.gov or (602) 364-3988
?
Form L-CRH (v. 201404)
Arizona Department of Insurance
CRIMINAL HISTORY CHECK ATTESTATION (FORM L-CRH)
Applicant’s last name Applicant’s first name Applicant’s middle name Jr/Sr/II/etc.
Applicant’s Employer that required Applicant
to undergo a criminal history records check
Date (month/year) when the criminal history
records check was performed
By signing this form, the Applicant and the Applicant’s Employer hereby attest and affirm that all of the
information on this form are true and correct to the best of the knowledge and belief of the Applicant
and the Applicant’s Employer:
1. As a condition of employment as a navigator or a certified application counselor, the Applicant was
required to undergo a criminal history records check on or after August 1, 2010, and on or before
July 23, 2014; AND,
2. The result of the criminal history records check did not contain information that would be grounds
for the denial of the license for which the Applicant is applying*.
*The Department of Insurance has grounds to deny a license if the Applicant admitted to, was ever found
guilty of, or was the subject of a judgment that found, any of the following: A felony (of any kind);
obtaining or attempting to obtain any type of license through misrepresentation or fraud; forging
another's name to any document related to an insurance transaction; withholding, misappropriating,
converting or stealing money or property; committing an insurance unfair trade practice or fraud; using
fraudulent, coercive or dishonest business practices including forgery with intent to defraud; conducting
business in an incompetent, untrustworthy or financially irresponsible manner; transacting, or helping
someone else transact, insurance without the required license authority; intentionally misrepresenting the
terms of an actual or proposed insurance contract or application for insurance; any misdemeanor
involving fraud or dishonesty.
Applicant’s signature
X ________________________________________________________________
Date
Printed name of the representative from the Applicant’s Employer
Employer’s/representative’s phone number
Email address of the representative from the Applicant’s Employer
Signature of the Applicant’s Employer representative
X ________________________________________________________________
Date