Fillable CERTIFICATE REQUEST FORM SECTION A: INSURANCE COMPANY INFORMATION (Arizona)

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CERTIFICATE REQUEST FORM SECTION A: INSURANCE COMPANY INFORMATION (Arizona)

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Financial Affairs Division
Arizona Department of Insurance
100 North 15
th
Avenue, Suite 261, Phoenix, Arizona 85007-2630
Web: https://insurance.az.gov
CERTIFICATE REQUEST FORM
SECTION A: INSURANCE COMPANY INFORMATION (SUBMIT ONE FORM PER COMPANY)
INSURANCE COMPANY NAME: STATE OF DOMICILE: NAIC NUMBER:
SECTION B: CERTIFICATE INFORMATION
TYPES OF CERTIFICATE: QUANTITY: COST: PRICE:
* Certificate of Authorization & Deposit
$3.00
Certificate of Valuation (Life Companies Only)
$3.00
* UCAA Certificate of Deposit
(Does not include WC deposit, if any)
$3.00
UCAA Certificate of Compliance (Domestic Only)
$3.00
MAKE CHECK PAYABLE TO: ARIZONA DEPARTMENT OF INSURANCE
(MUST BE PAID PRIOR TO CERTIFICATES BEING MAILED)
TOTAL:
* SECTION C: EFFECTIVE DATE REQUESTED FOR ABOVE: *______________ (EXAMPLE: 12/31/2019 OR CURRENT)
SECTION D: CONTACT INFORMATION
CONTACT:
COMPANY:
ADDRESS:
CITY, STATE, ZIP
PHONE:
EMAIL:
FEDEX
[RECOMMENDED]
UPS
PICKUP
NOTE: ENCLOSE SHIPPING LABEL OR AN ACCOUNT NUMBER FOR FEDEX.
CERTIFICATE(S) WILL BE SENT BY REGULAR MAIL IF FEDEX SHIPPING LABEL OR ACCOUNT NUMBER IS
NOT ENCLOSED OR LISTED ABOVE.
Q
uestions, contact Anthony McCormack at amccormack@azinsurance.gov
or (602) 364-3245.
Form E-CERTREQ (v. 20200110)
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CERTIFICATE REQUEST FORM SECTION A: INSURANCE COMPANY INFORMATION (Arizona)

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Completed 12 August 2020

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