Fillable FORM L-177: CHANGE TO MEMBERS, OFFICERS OR DIRECTORS (Arizona)

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FORM L-177: CHANGE TO MEMBERS, OFFICERS OR DIRECTORS (Arizona)

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Page 1
L-177 Rev 06/2018
Licensing Section
Arizona Department of Insurance
100 North 15
th
Avenue, Suite 102, Phoenix, Arizona 85007-2624
Phone: (602) 364-4457 | Toll-free: (877) 660-0964
Web: www.insurance.az.gov | E-mail: Licensing@azinsurance.gov
FORM L-177: CHANGE TO MEMBERS, OFFICERS OR DIRECTORS (PRINCIPALS)
The designated responsible producer (“DRP”) or a member, Officer, director, partner, etc. (collectively referred to as
“Officer’s”) must complete and submit this form within 30 calendar days of any change in the business-entity licensee’s
Officer’s. ARS § 20-286(C)(2). If removing or changing an Officer or Officer’s title, submit only this page.
BAIL BONDS AGENTS ONLY: You must submit fingerprints and $22.00 per card for each new Officer.
If you answer “YES” to one or more of the questions on page 2, you must include:
1) A SIGNED statement describing, in detail, all incidents, including names of all parties involved, dates and locations,
the names and localities of any courts and/or administrative agencies involved, the current status of each matter,
whether the conviction, plea or finding was for a felony or open-ended charge; AND
2) Copies of any and all indictments, complaints, plea agreements, orders of conviction, notices of hearing or trial,
sentencing orders, suspension/revocation orders and any other information which relates to each matter. If copies are
not available, provide a letter from the clerk of the pertinent court or the official involved stating the records are not
available and the reason.
Name of BUSINESS ENTITY LICENSEE
FEIN
AZ License No. (BUSINESS ENTITY)
DRP or Officer’s Last Name
DRP or Officer’s Middle Initial:
AZ License No. (DRP)
If the Officer’s is an INDIVIDUAL, enter the following (otherwise leave blank):
Officer’s Last Name:
First Name:
Middle Initial:
AZ License No. (if applicable):
If the Officer’s is a BUSINESS ENTITY, enter the following (otherwise leave blank):
Business Entity Name:
FEIN
Title (President, Member, CEO, etc.):
Check one box:
ADD
REMOVE
CHANGE
If the Officer’s is an INDIVIDUAL, enter the following (otherwise leave blank):
Officer’s Last Name:
First Name:
Middle Initial:
AZ License No. (if applicable):
If the Officer’s is a BUSINESS ENTITY, enter the following (otherwise leave blank):
Business Entity Name:
FEIN
Title (President, Member, CEO, etc.):
Check one box:
ADD
REMOVE
CHANGE
If the Officer’s is an INDIVIDUAL, enter the following (otherwise leave blank):
Officer’s Last Name:
First Name:
Middle Initial:
AZ License No. (if applicable):
If the Officer’s is a BUSINESS ENTITY, enter the following (otherwise leave blank):
Business Entity Name:
FEIN
Title (President, Member, CEO, etc.):
Check one box:
ADD
REMOVE
CHANGE
To list additional Officer’s, complete and include the Continuation Page following page 2.
AZ-9999999
Page 2
L-177 Rev 06/2018
Name of BUSINESS ENTITY LICENSEE
AZ License # - BUSINESS ENTITY
BACKGROUND QUESTIONS
You should provide a “Yes” answer even if you believe an incident has been cleared from an Officer’s record. Willful
misrepresentation of any fact required to be disclosed in any application or accompanying statement is a violation of law
and a ground to deny/revoke the license. For the purposes of this application, "judgment" includes, but is not limited to,
having been found guilty by judge or jury or pled guilty or no contest to any charge. You must answer “Yes” even if a
conviction was dismissed, expunged, pardoned, appealed, set aside, vacated or reversed, etc., even if the Officer had civil
rights restored, had a plea withdrawn, or was given probation, or a suspended sentence, was fined, or successfully
completed a diversion program.
A Has any individual designated in this report EVER had any professional, vocational, business
license or certification refused, denied, suspended, revoked or restricted, or a fine imposed by
any public authority? ........................................................................................................................
Yes
No
B. Has any individual designated in this report EVER withdrawn any application or surrendered
any license to avoid any disciplinary action or the denial of a license? ..........................................
Yes
No
C. Has any individual designated in this report EVER been convicted or found guilty of, had a
judgment made against for, or admitted to, any of the following:
1. A felony (of any kind)? ..............................................................................................................
Yes
No
2. Obtaining or attempting to obtain any type of license through misrepresentation or fraud? ....
Yes
No
3. Forging another's name to any document related to an insurance transaction? ......................
Yes
No
4. Withholding, misappropriating, converting or stealing money or property? ..............................
Yes
No
5. Committing an insurance unfair trade practice or fraud? ..........................................................
Yes
No
6. Using fraudulent, coercive or dishonest business practices, including forgery with intent to
defraud? ....................................................................................................................................
Yes
No
7. Conducting business in an incompetent, untrustworthy or financially irresponsible manner? .
Yes
No
8. Transacting, or helping someone else transact, insurance without the required license
authority? ..................................................................................................................................
Yes
No
9. Intentionally misrepresenting the terms of an actual or proposed insurance contract or
application for insurance? .........................................................................................................
Yes
No
D. Is any case currently pending against any individual designated in this report in any jurisdiction
alleging any offense listed in Question C? ......................................................................................
Yes
No
E. If the entity is not a bail bond agent license, answer “Not applicable” ............................................
Not applicable
Otherwise has any individual designated in this report EVER been convicted in any jurisdiction
of any crime (felony, open-ended or misdemeanor) that involved carrying, illegally using or
possessing a deadly weapon or dangerous instrument OR any crime (felony, open-ended or
misdemeanor) involving theft (that has not been previously disclosed in a written format by you
to this agency)? ...............................................................................................................................
Yes
No
AUTHORIZATION AND RELEASE: By signing and submitting this application, you agree to the
following:
• You authorize the Arizona Department of Insurance (“DEPARTMENT”) to conduct a background investigation to determine your fitness for an insurance
license. You agree to promptly respond to questions that may arise from the investigation.
• You authorize and request every person, firm, company, corporation, governmental agency, court, association or institution having control of documents,
records and other information about you to furnish the DEPARTMENT with any such information and you permit the DEPARTMENT, its employees,
agents or representatives, and your authorized insurers, to inspect and make copies of such documents, records and other information.
• You release, discharge and exonerate the DEPARTMENT, its employees, agents and representatives, the State of Arizona, your authorized insurers,
and any person furnishing information pursuant to this Authorization and Release from any and all liability that may arise from the investigation made
by the DEPARTMENT.
• You attest that you have read and understand the foregoing. You certify, under penalty of denial, suspension or revocation of the license and under any
other penalties that may apply that the answers, statements and information furnished in connection with this license application are true, correct and
complete to the best of your knowledge and belief.
SIGNATURE OF DESIGNATED RESPONSIBLE PRODUCER (DRP) OR OFFICER’S DATE
Submit your completed and signed Form L-177 to:
LICENSING SECTION, ARIZONA DEPARTMENT OF INSURANCE, 100 N 15 AVE STE 102, PHOENIX AZ 85007-2624
Print Form
L-177 Rev 06/2018
Continuation Page
ADOI
FORM L-177
CHANGE TO MEMBERS, OFFICERS OR DIRECTORS (PRINCIPALS)
Name of BUSINESS ENTITY LICENSEE
AZ License # - BUSINESS ENTITY
Sheet of
If the Officer’s is an INDIVIDUAL, enter the following (otherwise leave blank):
Officer’s Last Name:
First Name:
Middle Initial:
AZ License No. (if applicable):
If the Officer’s is a BUSINESS ENTITY, enter the following (otherwise leave blank):
Business Entity Name:
FEIN
Title (President, Member, CEO, etc.):
Check one box:
ADD
REMOVE
CHANGE
If the Officer’s is an INDIVIDUAL, enter the following (otherwise leave blank):
Officer’s Last Name:
First Name:
Middle Initial:
AZ License No. (if applicable):
If the Officer’s is a BUSINESS ENTITY, enter the following (otherwise leave blank):
Business Entity Name:
FEIN
Title (President, Member, CEO, etc.):
Check one box:
ADD
REMOVE
CHANGE
If the Officer’s is an INDIVIDUAL, enter the following (otherwise leave blank):
Officer’s Last Name:
First Name:
Middle Initial:
AZ License No. (if applicable):
If the Officer’s is a BUSINESS ENTITY, enter the following (otherwise leave blank):
Business Entity Name:
FEIN
Title (President, Member, CEO, etc.):
Check one box:
ADD
REMOVE
CHANGE
If the Officer’s is an INDIVIDUAL, enter the following (otherwise leave blank):
Officer’s Last Name:
First Name:
Middle Initial:
AZ License No. (if applicable):
If the Officer’s is a BUSINESS ENTITY, enter the following (otherwise leave blank):
Business Entity Name:
FEIN
Title (President, Member, CEO, etc.):
Check one box:
ADD
REMOVE
CHANGE
If the Officer’s is an INDIVIDUAL, enter the following (otherwise leave blank):
Officer’s Last Name:
First Name:
Middle Initial:
AZ License No. (if applicable):
If the Officer’s is a BUSINESS ENTITY, enter the following (otherwise leave blank):
Business Entity Name:
FEIN
Title (President, Member, CEO, etc.):
Check one box:
ADD
REMOVE
CHANGE
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FORM L-177: CHANGE TO MEMBERS, OFFICERS OR DIRECTORS (Arizona)

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Completed 12 August 2020

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