Fillable Financial Affairs Division Arizona Department of Insurance (Arizona)

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Financial Affairs Division Arizona Department of Insurance (Arizona)

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Financial Affairs Division
Arizona Department of Insurance
100 North 15th Avenue, Suite 261, Phoenix, Arizona 85007-2630
Phone: (602) 364-3245
E-Mail: financialfilings@azinsurance.gov | web: https://insurance.az.gov
E-178 (v.20180622)
Page 1 of 2
CERTIFICATE OF DISCLOSURE — ARS § 20-233
Insurer Name – provide exact name
Calendar or Fiscal Year End Date
NAIC Number
Domiciliary State
Contact Name
Contact Email Address
PART A: Has any person (a) who is currently an officer, director, incorporator, or (b) who holds or controls over ten
percent (10%) of the issued and outstanding common shares or ten percent (10%) of any other
proprietary, beneficial or membership in the insurer been:
1. Convicted or felony involving a transaction in securities, insurance consumer fraud or antitrust in any
state or federal jurisdiction within the seven-year period immediately preceding the execution of this
certificate?
YES
NO
(MUST BE ANSWERED)
2. Convicted of a felony, the essential elements of which consisted of fraud, misrepresentation, theft by
false pretenses or restraint of trade or monopoly in any state or federal jurisdiction within the seven-
year period immediately preceding the execution of this certificate?
YES
NO
(MUST BE ANSWERED)
3. Subject to an injunction, judgment, decree or permanent order of any state or federal court entered
within the seven-year period immediately preceding the execution of this certificate where such
injunction, judgment, decree or permanent order involved the violation of:
a. Fraud or registration provisions of the securities laws of that jurisdiction: or
b. The consumer fraud laws of that jurisdiction: or
c. The antitrust or restraint of trade laws of that jurisdiction; or
d. The insurance laws of that jurisdiction?
YES
NO
(MUST BE ANSWERED)
If your answer to any of the Items A1 through A3 is YES, the following information for each person must be attached.
1. Current full name and all prior names or aliases
used.
2. Full birth name.
3. Present home address.
4. Prior addresses (for immediately preceding seven-
year period).
5. Date and location of birth.
6. The nature and description of each conviction or
judicial action, the date and location, the court
and public agency involved and the file or cause
number of the case.
PART B: Has any officer, director, trustee, incorporator of the insurer or shareholder possessing or controlling ten
percent (10%) or more of any proprietary, beneficial or membership interest in the insurer served in any
such capacity or held such interest in any business entity which has been placed in bankruptcy or
receivership or had its charter revoked or Certificate of Authority suspended, refused renewal or revoked
YES
NO
(MUST BE ANSWERED)
Reset
email form
CERTIFICATE OF DISCLOSURE — ARS §20-233
Insurer Name (same as Page 1)
E-178 (v.20180622)
Page 2 of 2
If your answer to question B is YES, the following information for each entity must be attached.
1. Current and former names and addresses of the
entity.
2. Full name, all prior names or alias used, and
address of each person involved.
3. State(s) in which the entity:
a. was incorporated or organized.
b. has transacted business.
4. Dates of operation.
5. A description of the bankruptcy, receivership,
charter revocation, Certificate of Authority
suspension, renewal refusal or revocation,
including the date, the court or agency involved
and the file or cause number of the case.
PART C: TITLE INSURERS ONLY:
Have all income tax returns required by Title 43, Arizona Revised Statutes, been filed with the Arizona
Department of Revenue?
YES
NO
(MUST BE ANSWERED)
SIGNATURE AND VERIFICATION
Arizona law requires that this Certificate of Disclosure be executed by two executive officers or directors of the insurer. A
person executing or contributing information who intentionally makes an untrue statement of a material fact or withholds
any material fact with regard to the information required is guilty of a class 6 felony.
By signing below, each for him/herself acknowledges that he/she is an officer and/or director of said insurer, and that
under penalty of perjury, that this document together with any attachments is submitted in compliance with Arizona law.
Signature
I hereby intend by checking this box to be
Signature
I hereby intend by checking this box to be
the equivalent of my signature.
the equivalent of my signature.
Printed Name
Printed Name
Title
Title
Date
Date
DUE DATES:
Foreign and Alien domiciled insurers – On or before March 1 of each year.
Arizona domiciled insurers – On or before March 31 of each year.
Arizona domiciled unaffiliated credit life and disability reinsurers – On or before August 1 of each year.
Arizona domiciled captive insurers – On or before 90 days after the fiscal year end.
FILING INSTRUCTIONS:
Name the document using this format “E178-NAIC Number-Insurer Name” (e.g. E178-55555-INSURERNAME).
E-Mail completed FORM to financialfilings@azinsurance.gov.
DO NOT MAIL ORIGINAL / HARDCOPY DOCUMENT.
Certificate of Disclosure filings that are incomplete, have unacceptable signatures, or are late will subject an
insurer to payment of late fees not to exceed $25.00 for each day of delinquency.
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Financial Affairs Division Arizona Department of Insurance (Arizona)

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Completed 12 August 2020

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