Form E-AR-1 (v. 20200316)
Financial Affairs Division
Arizona Department of Insurance
100 North 15
th
Avenue, Suite 261 Phone: (602) 364-3999
Phoenix, Arizona 85007-2630 Email: financialfilings@azinsurance.gov
CERTIFICATE OF ASSUMING INSURER
I, ____________________________________________________ , _________________________________________
(name of officer) (title of officer)
of __________________________________________________________________________ , the assuming insurer
(name of assuming insurer)
under a reinsurance agreement with one or more insurers domiciled in ,
(name of state)
hereby certify that ______________________________________________________________ ("Assuming Insurer"):
(name of assuming insurer)
1. Submits to the jurisdiction of any court of competent jurisdiction in Arizona for the adjudication of any issues arising out
of the reinsurance agreement, agrees to comply with all requirements necessary to give such court jurisdiction, and will
abide by the final decision of such court or any appellate court in the event of an appeal. Nothing in this paragraph
constitutes or should be understood to constitute a waiver of Assuming Insurer's rights to commence an action in any
court of competent jurisdiction in the United States, to remove an action to a United States District Court, or to seek a
transfer of a case to another court as permitted by the laws of the United States or of any state in the United States.
This paragraph is not intended to conflict with or override the obligation of the parties to the reinsurance agreement to
arbitrate their disputes if such an obligation is created in the agreement.
2. Designates the Director of Insurance of the State of Arizona as its lawful attorney upon whom may be served any lawful
process in any action, suit or proceeding arising out of the reinsurance agreement instituted by or on behalf of the ceding
insurer. A copy of lawful process against or affecting the Assuming Insurer served upon the Director of Insurance should
be mailed to:
__________________________________
(name of person)
__________________________________
(name of company/entity/firm)
__________________________________
(mailing address)
__________________________________
(country, state and zip code)
3. Submits to the authority of the Insurance Director of Arizona to examine its books and records and agrees to bear the
expense of any such examination.
4. Submits with this form a current list of insurers domiciled in ______________________________________________
(ceding insurer’s state of domicile)
reinsured by Assuming Insurer and undertakes to submit additions to or deletions from the list to the Insurance Director
at least once per calendar quarter.
Dated:
(name of assuming insurer)
(signature of officer)
(title of officer)
