Fillable Form 1: Request For Information (RFI) Transmittal (Arizona)

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Form 1: Request For Information (RFI) Transmittal (Arizona)

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Form C-RFI (v. 20170205) Page 1 of 2
https://insurance.az.gov
Consumer Services Section
Arizona Department of Insurance
100 N. 15th Ave, Suite 261
Phoenix, Arizona 85007-2630
Phone: (602) 364-2499
Request For Information (“RFI”) Transmittal
ADOI Case #
Full Name of Underwriting Insurer: NAIC #:
1
st
Level Coverage: 2
nd
Level Coverage:
Insurer Contact Name: Phone: E-mail:
SECTION 1: Status of Complaint
Scenario A – The complaint has been resolved to the satisfaction of both the insurer and the insured/complainant. An
explanation of the resolution is provided in SECTION 2 of this form. Accompanying this form is a copy of the communication sent
to the complainant. PLEASE NOTE: The Department may ask for additional information at any time.
Scenario B – The complaint is about a matter outside the jurisdiction of the Arizona Department of Insurance. An
explanation along with proof of non-jurisdiction is
provided in SECTION 2 of this form.
Scenario C – The complaint has not been resolved; the company’s position remains unchanged. Accompanying this form
are all the items the Department of Insurance requested in its correspondence concerning the complaint.
SECTION 2: Explanation of Complaint Status
SECTION 3: Type of Coverage. Review the categories of insurance shown below and on Page 2. Select one (1) FIRST-LEVEL
COVERAGE type and up to three (3) associated SECOND-LEVEL COVERAGE types that apply to the complaint.
AUTO HOMEOWNERS
FIRST-LEVEL COVERAGE
SECOND-LEVEL COVERAGE
FIRST-LEVEL COVERAGE
SECOND-LEVEL COVERAGE
0105 Indiv. Private Passenge
r
0130 Liability
0305 Homeowners 0325 Liability
0107 Group Private Pssngr.
0135 Physical Damage
0307 Group Homeowners 0330 Theft
0110 Commercial
0137 Collision
0310 Farmowner/Ranchowne
r
0333 Earthquake
0115 Motorcycle
0138 Comprehensive
0315 Mobile Homeowne
r
0334 Flood
0120 Moto
r
home / RV
0140 Medical Payments
0317 Condo/Town 0335 Fire - Real Property
0123 Moto
r
sports
0145 UM/UIM
0318 Renters/Tenants 0336 Single Interest
0124 Rental
0150 No-Fault / PIP (N/A in AZ)
0337 Medical Payments
0151 Personal Effects Coverage
0338 In Home / Incidental
0152 Policy Proof of Interest
0340 Personal Property
0153 Rental Reimbursement
0341 Residual Mkt./JUA Related
0154 Towing
0342 Replacement Cost
0155 Residual Mkt./JUA Related 0343 Loss of Use
0156 Physical Damage Waive
r
0344 Windstorm
0157 Collision Damage Waive
r
0385 Surplus Lines
0158 Supplemental Liability
0159 Personal Passenger Protctn.
0185 Surplus Lines
Clear Form
Form C-RFI (v. 20200221) Page 2 of 2
Request For Information (“RFI”) Transmittal (continued)
ADOI Case #
Full Name of Underwriting Insurer: NAIC #:
FIRE, ALLIED LINES & COMMERCIAL MULTI-PERIL
MISCELLANEOUS
FIRST-LEVEL COVERAGE
SECOND-LEVEL COVERAGE
FIRST-LEVEL COVERAGE
FIRST-LEVEL COVERAGE (cont’d)
0205 Fire, Allied Lines 0225 Liability
0705 Workers’ Compensation 0737 Watercraft
0207 Crop/Hail 0230 Theft
0710 Fidelity & Surety 0738 Aircraft
0210 Commercial Multi-Peril 0233 Windstorm
0715 Ocean Marine 0739 Bail Bonds
0215 Credit Property 0235 Fire - Real Property
0720 Inland Marine 0740 Extended Warranty and
0217 Dwelling Fire 0240 Personal Property
0725 Title
Service Contracts
0218 Builder’s Risk 0243 Residual Mkt./JUA Related
0727 Home/Incidental Business
0741 Federal Programs
0245 State Specific
0730 Mortgage Guaranty
0742 Federal Crop
0285 Surplus Lines
0733 Boiler Machinery 0743 Federal Flood
0734 PMI
0744 Travel
0736 Surplus Lines
LIABILITY
LIFE & ANNUITY
FIRST-LEVEL COVERAGE
SECOND-LEVEL COVERAGE
FIRST-LEVEL COVERAGE
SECOND-LEVEL COVERAGE
0605 General 0625 Employment Policy
0405 Individual Life
0435 Accidntl Death/Dismbrmnt
0610 Products 0630 Excess Loss
0410 Group Life
0440 Association
0615 Professional E & O 0635 Medical Malpractice
0415 Indiv. Annuities
0445 Equity Indexed
0617 Umbrella 0640 Pollution 0417 Group Annuities 0450 Fixed
0618 Directors & Officers 0685 Surplus Lines 0420 Credit Life 0455 Premium Waive
0425 Accelerated Benefits 0460 Single Premium
0465 Term
0470 Universal
0475 Variable
0480 Whole
A
CCIDENT & HEALTH
► Was the policy sold through the federal Health Insurance Exchange? Yes No
FIRST-LEVEL COVERAGE
SECOND-LEVEL COVERAGE (cont’d) SECOND-LEVEL COVERAGE (cont’d)
0505 Individual
0534 Multistate 0535 Medicare Supplement
0510 Group 0537 Stand-alone Dental 0536 Medicare Select
0515 Credit 0538 Autism/PDD 0549 Medicare Risk
0539 Student Health 0575 Medicare Advantage
SECOND-LEVEL COVERAGE (may relate 0540 Long-Term Care 0576 Medicare RX Drug/Part D
to any first
-
level A&H coverage) 0541 Home Health Care 0577 Medicare Supplement
0520 Accident Only 0542 Short-term Limited-duration 0578 Medicare Select
0521 Grandfathered 0543 Mental Health 0580 Medicare Supp Plan A
0522 Exchange 0545 Dental 0581 Medicare Supp Plan B
0523 Pharmacy Benefits 0546 Occupational Accident 0582 Medicare Supp Plan C
0524 Catastrophic 0547 Limited Benefits 0583 Medicare Supp Plan D
0525 Disability Income 0548 Chiropractic 0584 Medicare Supp Plan E
0526 Bronze
0550 Hospital Indemnity
0585 Medicare Supp Plan F
0527 Silve
r
0551 Vision
0586 Medicare Supp Plan G
0528 Gold
0552 HIPAA
0587 Medicare Supp Plan H
0529 Platinum
0553 Unemployment
0588 Medicare Supp Plan I
0530 Health Only 0554 Pre-existing Condition 0589 Medicare Supp Plan J
0531 Small Group 0555 Cancer/Dread Disease 0590 Medicare Supp Plan K
0532 Large Group 0556 Self Funded/ERISA 0591 Medicare Supp Plan L
0533 Child Only 0557 COBRA 0592 Medicare Supp Plan M
0558 HMO 0593 Medicare Supp Plan N
0559 PPO 0594 Other Medicare Supp Plans
0595 Pre-standardized Med Supp
✔
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Form 1: Request For Information (RFI) Transmittal (Arizona)

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Completed 20 July 2020

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