Fillable FORM L-LTD: Application for a Business-entity Limited-line Insurance (Arizona)

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FORM L-LTD: Application for a Business-entity Limited-line Insurance (Arizona)

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FORM L-LTD
Application for a Business-entity
Limited-line Insurance License
(Portable Electronics Vendor, Rental Car Agent,
Self-service Storage Agent, or Travel Insurance Producer)
Use Form L-176 if applying for a business-entity license that is not listed in parentheses
toward the top of this page.
Use Form L-169 if you are an individual applying for a Self-service Storage Agent license.
Carefully read instructions. You may need to submit additional forms or documents with
your application. If your application does not contain all the necessary forms or
documents, or is otherwise not complete, the application will be returned as deficient.
Clearly print in ink or type all information and carefully review the application before
submitting it.
Ensure the application is signed and dated in the Authorization and Release section.
Mail or deliver the completed application with all required documents and fees to:
INSURANCE LICENSING SECTION, 100 NORTH 15 AVENUE, SUITE 102, PHOENIX, AZ, 85007-2624
QUESTIONS? Before calling the Department of Insurance, look for answers on the
PRODUCERS page of the Department of Insurance Internet web site (www.azinsurance.gov).
For questions not addressed on our web site, contact the Insurance Licensing Section:
E-mail: Licensing@azinsurance.gov
Phone: 602-364-4457, or 877-660-0964 if calling long-distance within Arizona.
Page 2 of 2 INSTRUCTIONS to Form L-LTD (v 20180618)
INSTRUCTIONS FOR FORM L-LTD
Business-entity Limited-lines License Application
KEEP THESE INSTRUCTIONS -- Do not return them with your license application.
1. OFFICE LOCATIONS. If the applicant transacts business at any office location other than the
address provided in Section I, submit Form L-LOC with the application.
2. FEE: $120.00 (for a new license OR to add authority to an existing license)
• Fees are NON-REFUNDABLE and are not prorated [ARS § 20-167(B)].
• Make your check or money order payable to INSURANCE LICENSING SECTION.
• The fee to obtain a new Arizona insurance license OR to add authority to an existing license is
$120.00.
3. IF YOU ANSWERED “YES” TO ONE OR MORE OF THE QUESTIONS IN SECTION V, include:
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 disposition of each matter,
whether the conviction, plea or finding was for a felony or open-ended charge;
AND
b. 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, you must provide as a part of this
application a letter from the clerk of the pertinent court or the official involved stating the
records are not available and the reason.
4. ASSUMED NAME (OR DBA). While conducting insurance business, you must use your legal
name or an acceptable assumed name. To use an assumed name, submit Form L-193.
THE ARIZONA DEPARTMENT OF INSURANCE IS AN EQUAL EMPLOYMENT OPPORTUNITY
AGENCY THAT COMPLIES WITH THE AMERICANS WITH DISABILITIES ACT ("ADA')_OF 1990.
PERSONS WITH DISABILITIES MAY REQUEST ACCOMMODATION BY CONTACTING THE ADA
COORDINATOR AT 602-364-3471. REQUESTS SHOULD BE MADE AS EARLY AS POSSILE TO
ALLOW TIME FOR THE DEPARTMENT TO MAKE APPROPRIATE ARRANGEMENTS.
Page 1 of 2 Form L-LTD (v 20180618)
APPLICATION FOR A BUSINESS-ENTITY LIMITED-LINES LICENSE (FORM L-LTD)
Self-service Storage Agent ● Rental Car Agent ● Portable Electronics Vendor ● Travel Insurance Producer
1. Use Form L-176 if applying for a business-entity license that is not listed toward the top of this page.
2. Use Form L-169 if you are an individual applying for a Self-service Storage Agent license.
3. CAREFULLY READ THE INSTRUCTION PAGES.
4. Complete BOTH PAGES (printed in ink or typed) of this form and fulfill all other requirements described in the
instruction pages. Additionally requi
red forms are available on our Internet web site, at www.azinsurance.gov
5. Send or deliver application materials and fee payment to:
INSURANCE
LICENSING SECTION, 100 North 15 Avenue, Suite 102, Phoenix, AZ, 85007-2624
SECTION I: BUSINESS INFORMATION
Full Name of Applicant (If intending to use an assumed name or d.b.a. name, also see instructions) FEIN #
Physical street address of record (may not be P.O. box) City State Zip Code
Mailing address to appear on license (if left blank, box B address will appear on license)* City State Zip Code
Telephone Number * The physical street address may not be a post office box. The mailing address may be a post office box if desired.
NOTE
: If the applicant shall transact business at locations other than the physical address identified in
Section I, applicant must attach form L-LOC.
Fax Number (optional) E-mail Address (optional)
SECTION II: LICENSE TYPE Enter an “X” to the left of the license authority for which you are applying.
Portable Electronics Vendor Rental Car Agent Self-service Storage Agent Travel Insurance Producer
SECTION III: PRINCIPALS OF THE APPLICANT
Is the applicant a portable electronics vendor that derives more than 50% of its revenue from selling portable electronics
insurance?
Yes No. If “No,” skip the remainder of this section. If “Yes,” the applicant must list all its officers and
directors, and all shareholders of record having beneficial ownership of 10% or more of any class of securities registered
under the federal securities law. Provide additional signed and dated sheets as required.
Name: Title:
Name: Title:
Name: Title:
Name: Title:
SECTION IV: DESIGNATED RESPONSIBLE LICENSED PRODUCER (Travel Insurance Producer ONLY –
otherwise skip). Enter the FULL name and Arizona insurance license number of the individual who shall be responsible for
the applicant's compliance with Arizona insurance laws.
Name: AZ License #:
SPACE BELOW IS FOR INSURANCE DEPARTMENT USE ONLY
AZ License #: L-LTD
TF#:
56 Quad Other (120)
License Type: _______________________________
License Tech Initials ___________
Page 2 of 2 Form L-LTD (v 20180618)
SECTION V: ADDITIONAL INFORMATION Carefully respond to each question. You should provide a “YES”
answer even if you believe an incident has been cleared from your 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 your application.
NOTE: You must provide additional information if you respond “YES” to any of the following.
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., OR even if applicant had civil rights restored, had a plea withdrawn, or was
given probation, a suspended sentence or a fine, or successfully completed a diversion program.
SECTION VI: AUTHORIZATION AND RELEASE By my signature below, I hereby attest and affirm all the following:
• I am the authorized individual who represents the applicant named hereon which is organized under the laws of the State of Arizona or
possesses official authority to do business in Arizona;
• I have read the application and accompanying materials, and each statement, answer, attachment and enclosure provided in the
application and accompanying materials are true, complete and correct;
• I acknowledge that if there exists any fraud or misrepresentation in attempting to obtain any insurance license in this State, the Director
of Insurance may refuse to accept any application for a license;
• I understand that pursuant to A.R.S. § 20-291, application for and acceptance of a non-resident license constitutes an irrevocable
appointment of the Director of insurance as attorney of the licensee for the acceptance of service of process issued in this state in any
action or proceeding against the licensee arising out of such licensing or out of transactions under the license;
• Service of process on the director on behalf of a non-resident licensee constitutes service on the licensee as though the licensee were
personally served with process in this state.
• Limited Line Travel Producers only. I certify to the Department that the registered travel retailer is not in violation of 18 United States
code section 1033.
Signature of a principal of the applicant
______________________________________________
Printed or typed name of signer
_______________________________________________
Date
_____________________
Title
______________________________________________
Email address:
_______________________________________________
Phone
_____________________
A Has the applicant or any individual designated in the application as a principal or individual who is to
exercise the powers conferred by the license 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 the applicant or any individual designated in the application as a principal or individual who is to
exercise the powers conferred by the license EVER withdrawn any application or surrendered any
license to avoid any disciplinary action or the denial of a license?
Yes No
C. Has the applicant or any individual designated in the application as a principal or individual who is to exercise the
powers conferred by the license 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)? .......................................................................................................................
2. Obtaining or attempting to obtain any type of license through misrepresentation or fraud? .............
3. Forging another's name to any document related to an insurance transaction? ...............................
4. Withholding, misappropriating, converting or stealing money or property?.......................................
5. Committing an insurance unfair trade practice or fraud?...................................................................
6. Using fraudulent, coercive or dishonest business practices including forgery with intent to
defraud? .............................................................................................................................................
7. Conducting business in an incompetent, untrustworthy or financially irresponsible manner? ..........
8. Transacting, or helping someone else transact, insurance without the required license authority? .
9. Intentionally misrepresenting the terms of an actual or proposed insurance contract or application
for insurance? ....................................................................................................................................
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
D. Is ANY case currently pending against the applicant or any individual designated in the application as
a principal or individual who is to exercise the powers conferred by the license in any jurisdiction
accusing you of any issue listed in Question C?: .....................................................................................
Yes No
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FORM L-LTD: Application for a Business-entity Limited-line Insurance (Arizona)

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Completed 12 August 2020

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