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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E-HCSO.13 (v. 20181218) Page 1 of 1
Financial Affairs Division
Arizona Department of Insurance
100 North 15
th
Avenue, Suite 261, Phoenix, Arizona 85007-2630
Phone: (602) 364-3986
Web: https://insurance.az.gov/
CERTIFICATE OF ADVERTISING COMPLIANCE
DUE MARCH 31
Mail this certificate to the address shown above
ANNUAL STATEMENT CALENDAR YEAR FOR WHICH THIS CERTIFICATE IS FILED:
I, , certify that to the best of my knowledge,
information and belief, all written solicitations disseminated during the preceding statement year
complied or were made to comply with the provisions of Title 20, Chapter 4, Article 9 and
Administrative Rule R20-6-405(K), the Health Care Services Organizations rule, and that no forms of
solicitations were disseminated without the prior approval of the Director of Insurance.
Name of Health Care Services Organization
Name of Officer/Affiant
Officer's Title
Date
Signature of Officer/Affiant
Subscribed and sworn to before me this
day of
,
, Notary Public.
My commission expires
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Financial Affairs Division Arizona Department of Insurance CERTIFICATE (Arizona)

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Completed 12 August 2020

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