L-LSB Rev. 20180618
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: https://insurance.az.gov | E-mail: Licensing@azinsurance.gov
FORM L-LSB: LIFE SETTLEMENT BROKER NOTIFICATION OF LIFE SETTLEMENT BROKER
You must hold an insurance producer license with life insurance authority in order to act as a life settlement
broker. Arizona Revised Statutes (“A.R.S.”) § 20-3202(F)(1).
• Complete and file this form within the first 30 days of operating as a broker. A.R.S. § 20-3202(F)(2).
• Use our “License Search” web page https://insurance.az.gov/license-search to locate your license.
Enter your full name, Arizona insurance license number, and license expiration date below.
AZ License No. (AZ license holder)
Include with this form, the appropriate non-refundable) life settlement broker application fee shown below.
A.R.S. § 20-3202(F)(3).
$250.00 to add authority to an existing insurance producer license that expires in less than two years; OR
$500.00 to add authority to an existing insurance producer license that expires in two years or more.
APPLICANT CERTIFICATION
To be completed by the applicant or, if the applicant is a business entity, the applicant’s designated
responsible licensed producer.
By my signature below, I hereby certify and attest that:
• I am familiar with and understand that I must comply with the provisions of A.R.S. Title 20, Ch. 22
and other laws that govern life settlements.
• I am aware that I may also be required to be registered as a securities dealer with the Arizona
Corporation Commission pursuant to A.R.S. §§ 44-1841, 44-1850, et al.
SIGNATURE OF APPLICANT
TYPED OR PRINTED NAME DATE
FOR USE ONLY BY DEPARTMENT OF INSURANCE
272 2-year LSB (250)
Click on the box below to apply your digital signature.
If you do not wish to apply a digital signature, SIGN AND DATE your signature in the
space provided after printing your application.
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