100 North 15 Avenue, Suite 261 | Phoenix, Arizona 85007-2630
CERTIFICATE OF ASSUMED BUSINESS NAME
602-364-4457 |
insurancelicensing@difi.az.gov
Make sure no one else is using a name that is substantially similar to the name you wish to use:
To find out if another licensee is using a substantially similar name, visit the department’s website online at
https://difi.az.gov/. Hover over the “General Information” tab then over “Learn About Insurance” then click “Find A
Producer (License Search).
To find out if anyone has registered a substantially similar name, visit the Arizona Corporation Commission’s
website online at http://ecorp.azcc.gov. Use the “eCorp” search option to conduct your search.
1. If this certificate is for an individual or business that already has an Arizona
insurance license, enter the license number; otherwise leave blank ............... ►
AZ INSURANCE LICENSE NUMBER
2. Is the person seeking to use the assumed business name a BUSINESS ENTITY or an INDIVIDUAL?
BUSINESS ENTITY (Go to #3) INDIVIDUAL (Skip #3; go to #4)
3. Enter the (genuine/legal) name of the business entity (skip #4 and go to #5)
4. Genuine/legal (“FULL”) Last Name
5. If you want an existing assumed name removed from your license, enter that name here
6. If you want an assumed name added to your license, enter that name here.
ACKNOWLEDGMENT AND CERTIFICATION
As the person conducting or intending to conduct insurance under the assumed name on this certificate, or as the designated responsible
producer (DRLP) of a firm or corporation (business entity) that is conducting or intends to conduct insurance under the assumed name
on this certificate, by my signature below, I hereby acknowledge and certify that:
1) T
HIS FORM DOES NOT CONSTITUTE AN INSURANCE LICENSE. If I establish and intend to sell, solicit or negotiate insurance through a firm
or corporation that uses the name shown on this form, I understand that the firm or corporation must apply for and be issued an
Arizona insurance license prior to conducting insurance business in Arizona.
2) The Director of Insurance may deny the use of an assumed business name, require the use of a different assumed business name
or require the use of an assumed business name if either:
• the name is so similar to that of any firm, corporation or other entity already licensed or using a duly filed assumed name that
use of the name pursuant to this certificate may cause uncertainty or confusion; or,
• the name would tend to deceive or mislead the public as to the nature of the business that is or will be conducted.
3) The licensee must notify the Department of Insurance in writing within 30 days after any material change to the information provided
on this form.
4) Filing this certificate does not legally reserve the assumed business name as a trade name.
NOTE: You can reserve a trade name with the Arizona Secretary of State. If you received a Trade Name Certificate from the Arizona
Secretary of State, please attach it to this certificate. If you do not register your name with the Arizona Secretary of State and we
receive a license application from a person whose genuine name or trade name is substantially similar to your assumed name, we
may require you to stop using the assumed name.
Click on the signature box to apply your digital signature. If you do not wish to apply a digital signature,
SIGN AND DATE your signature in the space provided above after printing your application.
click to sign
signature
click to edit
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