Form E-LSP4 (v. 20180716) Page 1 of 2
Financial Affairs Division
Ariz
ona Department of Insurance
100
North 15th Avenue, Suite 102
Phoenix, AZ 85007-2624
LIFE SETTLEMENT PROVIDER
FORM E-LSP4: STATUTORY AGENT APPOINTMENT AND ACCEPTANCE
INSTRUCTIONS: File Part A and Part B together (do not file one without the other). Part A must be completed by
the provider/applicant. Part B must be completed by the person who shall serve as the statutory agent for the
provider/applicant.
PART A: STATEMENT OF CHANGE OF STATUTORY AGENT
Provider/Applicant Name Federal Employer Identification
Number (FEIN)
Pursuant to the provisions of ARS § 20-3202(H), the undersigned, on behalf the above-named
provider/applicant, hereby submits the following information:
FIRST: The name and address of its current statutory agent are:
Name:
Address:
City: State: ZIP Code:
SECOND:
The statutory agent of the provider/applicant has changed. The name and address of the
successor statutory agent are:
Name:
Address:
City: State: ZIP Code:
THIRD:
The change to the statutory agent has been duly authorized by the provider/applicant. If the
provider/applicant is other than an individual, the provider/applicant has attached a certified
copy of the provider/applicant’s Board of Director’s authorizing resolution.
SIGNED and DATED this ___________ day of ___________________________, ___________
By ___________________________________________
Printed Name
Its ___________________________________________ ________________________________
Title Signature
