Form E126XS (v. 20180827)
Financial Affairs Division
Arizona Department of Insurance
100 North 15
th
Avenue, Suite 102, Phoenix, Arizona 85007-2624
Phone: (602) 364-3999
Web: https://insurance.az.gov/
APPLICATION AND ORDER FOR RELEASE OF EXCESS DEPOSIT
A. Application (To be completed by Applicant)
(Name of Company) (NAIC#)
A corporation, is filing this application as required by A.R.S. § 20-588 for release of
funds deposited with the Arizona State Treasurer, which total $ in face value.
I certify, as a duly authorized officer, that such funds are in excess of the required deposit amount of
$_______________ And that upon release, the remaining amount of funds on deposit, measured as the
lessor of $ in face value or $ in current Account Value*,
satisfy our deposit requirement.
Signed: Dated:
In my capacity as:
We have attached a properly completed and signed Release Form E126CD for each Certificate of Deposit to
be released, if applicable.
Please mail our copy of this Order to:
B. Order (To be completed by Department of Insurance)
By authority of the Director of Insurance delegated in accordance with A.R.S. § 20-148 and A.R.S. § 20-150,
and in accordance with A.R.S. § 20-588, IT IS HEREBY ORDERED approving the application for release of
excess deposit set forth above, effective this day of , .
Assistant Director, Financial Affairs Division
Mailed this day of , by
*Account Value applies to deposits of marketable securities and is defined in your Custody Agreement as ”At any
given time, the sum of the lesser of the market value, par value or amortized value of each Eligible Security
held in the Account.”
