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

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Financial Affairs Division Arizona Department of Insurance REQUEST (Arizona)

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Form E126LOC (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/
REQUEST FOR RELEASE OF LETTER OF CREDIT
REQUEST IS MADE FOR RELEASE OF THE FOLLOWING LETTER OF CREDIT FROM SAFEKEEPING
WITH THE ARIZONA DEPARTMENT OF INSURANCE WHO IS HOLDING THE LETTER OF CREDIT FOR:
(Name of company) (NAIC #)
LETTER OF CREDIT DESCRIPTION:
Name of Financial Institution:
Face Amount:
$
Expiration Date:
Letter of Credit Number:
INSTRUCTIONS FOR DELIVERY OF THE RELEASED LETTER OF CREDIT ARE:
A.
The Company authorizes
of
to pick up the Letter of Credit from the Arizona Department of Insurance.
OR
B.
Ordinary U.S. mail delivery directed to:
Recipient Name and Title:
Company or Firm Name:
Street Address:
City, State, Zip:
BY THIS AUTHORIZED REPRESENTATIVE OF THE COMPANY: (authorizing resolution may be required)
Name:
Title:
Signature:
Date:
CONTACT PERSON:
Title:
Telephone
Email
DELIVER THIS FORM TO THE ADDRESS SHOWN ABOVE
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Financial Affairs Division Arizona Department of Insurance REQUEST (Arizona)

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Completed 12 August 2020

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