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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CERTIFICATE REQUEST FORM
SECTION A: INSURANCE COMPANY INFORMATION (SUBMIT ONE FORM PER COMPANY)
INSURANCE COMPANY NAME: STATE OF DOMICILE: NAIC
NUMBER:
AZ
SECTION B: CERTIFICATE INFORMATION
TYPES OF CERTIFICATE:
PLACE A 1 IN
APPLICABLE
BOX:
C
OST:
TOTAL
PRICE:
Certificate of Compliance for Captive Insurance Company
SECTION C: EFFECTIVE DATE REQUESTED FOR ABOVE: ______________ (EXAMPLE: 12/31/2020 OR CURRENT)
SECTION D: CONTACT INFORMATION
CONTACT:
COMPANY:
ADDRESS:
CITY, STATE, ZIP
PHONE:
EMAIL FOR DELIVERY:
Section B Notes – Place a number 1 in the applicable (certificate wanted) box.
Send the Certificate Request Form to francine.juarez@difi.az.gov
.
Send the check, made payable to the Arizona Department of Insurance and Financial Institutions, and a copy of the
Certificate Request Form to:
Insurance Financial Affairs Division
Arizona Department of Insurance and Financial Institutions
100 N. 15th Ave., Suite 261
Phoenix, AZ 85007-2630
CERTIFICATE WILL BE SENT BY EMAIL.
Questions, contact Francine Juarez at francine.juarez@difi.az.gov
or (602) 364-4490.
Form E-CERTREQCAPTIVE (v 20210707)
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CERTIFICATE REQUEST FORM SECTION A: INSURANCE COMPANY INFORMATION (Arizona)

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Completed 1 July 2022

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