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, AZ 85007-2630
Phone: (602) 364-3450
Web: https://insurance.az.gov
Page 1 of 3
E-R002 (v 20180619
FOREIGN RISK RETENTION GROUP REGISTRATION APPLICATION
NEW REGISTRATON
UPDATED REGISTRATION
Federal Tax ID Number:
NAIC Number:
Risk Retention Group:
Mailing Address:
City:
ZIP:
SECTION A: GENERAL INFORMATION
1. Does the applicant plan to transact insurance under any name other than as shown above or under its initials? If
yes, list the name(s) below: YES NO
2. Street address of principal administrative office:
Address:
City:
State:
Zip:
Telephone #:
Fax #:
Toll Free #:
3. Designated contact Information:
Contact Name:
Telephone #:
E-Mail Address:
4. The Risk Retention Group is chartered and licensed as a liability insurance company under the laws of the state
of:
Domicile State:
Original Incorporation / Organization Date:
Reset
FOREIGN RISK RETENTION GROUP REGISTRATION APPLICATION
Page 2 of 3
E-R002 (v 20180619)
5. The Risk Retention Group is authorized to engage in the transaction of insurance in the following lines under the
laws of the chartering state (attach copy of Certificate of Authority):
6. Check one of the following:
The owners of the Risk Retention Group are the only persons who comprise the membership of the
group and who are provided insurance by the group.
The sole owner of the Risk Retention Group is:
7. The Risk Retention Group is composed of members who are engaged in the following described business or
activity which is similar or related with respect to the liability to which such members are exposed by virtue of
related, similar or common business, trade, product, service, premises or operation:
SECTION B: DISCLOSURES
Carefully read the questions below and answer each one ‘Yes’ or ‘No’
Yes
No
The primary activity of the Risk Retention Group consists of assuming and spreading all,
or any portion of, the liability exposure of its members.
Yes
No
The Risk Retention Group is organized for the primary purpose of assuming and
spreading all or any portion of the liability exposure of its members.
Yes
No
The Risk Retention Group does not exclude any person from membership in the group
solely to provide for members of the group a competitive advantage over such a person.
Yes
No
The activities of the risk retention group do not include providing insurance other than the
liability insurance for assuming and spreading all or any portion of the similar or related
liability exposure of its group members.
Yes
No
The activities of the Risk Retention Group do not include providing insurance other than
reinsurance with respect to the similar or related liability exposure of another Risk
Retention Group (or member of such other Risk Retention Group) engaged in businesses
or activities which qualify such other Risk Retention Group (or member) for membership
in the group.
FOREIGN RISK RETENTION GROUP REGISTRATION APPLICATION
Page 3 of 3
E-R002 (v 20180619)
SECTION C: Affidavit that Application & Attachments are True & Correct
I,
Name
hereby being duly sworn, depose and say that
Title
as
I am a principal or an officer of:
Risk Retention Group Name
,
the registrant, that I have the authority to bind the registrant, and that all information previously provided in all sections of
this registration statement and in all attachments thereto are true and correct to the best of our knowledge and belief, and
I understand that any misrepresentation made in this registration statement or its attachments thereto are grounds for
denial or removal from the Qualified List of Registered Foreign Risk Retention Groups of this State.
Signature
Date
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Financial Affairs Division Arizona Department of Insurance (Arizona)

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Completed 12 August 2020

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