Form E-AR-1 (v 20211101)
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 the Arizona Department of Insurance and Financial Institutions (“Director”) 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 and Financial Institutions 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 Director 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 Director at least
once per calendar quarter.
Dated:
(name of assuming insurer)
(signature of officer)
(title of officer)
Send the document to financialfilings@difi.az.gov.
