Fillable Financial Affairs Division Arizona Department of Insurance CERTIFICATE (Arizona)

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Financial Affairs Division Arizona Department of Insurance CERTIFICATE (Arizona)

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Form E125CD (v. 20180824)
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/
CERTIFICATE OF DEPOSIT TRANSMITTAL
DELIVERY OF THE FOLLOWING CERTIFICATE OF DEPOSIT IS MADE FOR SAFEKEEPING WITH
THE ARIZONA STATE TREASURER ON BEHALF OF THE DIRECTOR OF INSURANCE, WHO WILL,
IN TURN, HOLD THE SECURITY FOR:
(Complete Name of Company) (NAIC / AZ CO #)
CERTIFICATE OF DEPOSIT DESCRIPTION:
Name of Financial Institution:
Face Amount:
$
Interest
Rate:
%
Maturity Date:
Certificate of Deposit Number:
Automatic Renewal? (check one):
YES NO
Financial Institution Account Number:
(if different than CD Number)
TO BE CLASSIFIED AS A: (Check one option)
HCSO Escrow Reserve Deposit – ARS § 20-1056
Ordinary Statutory Deposit required for authority to transact in Arizona
Retaliatory Deposit - § ARS 20-230
Security Deposit for the benefit of ARIZONA policyholders only
Workers’ Compensation Deposit – ARS § 23-961
TO BE DELIVERED FOR DEPOSIT: (Check one option)
A.
In person
B.
By mail
AS INSTRUCTED BY THIS AUTHORIZED REPRESENTATIVE OF THE COMPANY:
Name:
Title:
Signature:
Date:
CONTACT PERSON:
Title:
Telephone number:
Email:
DELIVER THIS FORM TO THE ADDRESS SHOWN ABOVE.
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Financial Affairs Division Arizona Department of Insurance CERTIFICATE (Arizona)

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Completed 1 July 2022

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