Form E-111: Renewal Application for Life and Health Administrator Registration (v. 20181217)
Section E, Item 12 is purposely omitted.
13. ENCLOSE Form E-100-B to report the name and title of each “individual responsible for the administrator’s affairs”
for whom an NAIC Biographical Affidavit Form 11 was not previously submitted to the Arizona Department of
Insurance by the applicant. If biographical affidavits were previously submitted for all individuals responsible for the
administrator’s affairs, enclose Form E-100-B and enter “NONE” for the first item in Section B.
“Individuals responsible for the administrator’s affairs” include:
All members of the board of directors/trustees, members of the executive committee or any other governing
board of the committee, PLUS
If applicant is a corporation, all officers and all shareholders that directly or indirectly hold at least 10% of the
voting securities of the applicant if a corporation, AND
If applicant is a partnership or association, all partners.
ENCLOSE an NAIC Biographical Affidavit Form 11 for each individual listed on Form E-100-B.
ARS § 20-485.12(B)(5).
IMPORTANT! The Department will investigate information provided and may deny a license if the applicant fails to
provide complete and truthful information about itself and the individuals responsible for the administrator’s affairs.
14. Did any NAIC Biographical Affidavit Form 11 submitted with this application contain a “Yes” response to
one or more question in Item 11? ARS § 20-485.12(B)(5)
YES. ENCLOSE a copy of the complaint and the filed adjudication or settlement for each matter.
NO.
15. OTHER REQUIRED ENCLOSURES based on responses in other parts of this application form:
You responded YES to Section D, Item 1 or 3. You must ENCLOSE a signed statement detailing all incidents including
names of all parties involved, dates and locations, the names and localities of any courts and administrative agencies
involved, the disposition of each matter, whether the conviction, plea or finding was for a felony or open-ended charge;
AND, you must ENCLOSE copies of any and all indictments, complaints, plea agreements, orders of conviction, notices
of hearing or trial, sentencing orders, suspension/revocation orders and any other information that relates to each
matter. If copies are not available, you must provide as a part of this application a letter from the clerk of the pertinent
court or the official involved stating the records are not available and the reason.
SECTION F: ATTESTATION (must be signed by two officers of the administrator)
All of the information contained in this application, including but not limited to the annual financial statement and all other
enclosures and attachments, are true and correct to the best of our knowledge and belief.
_______________________________________ _____________________________ ________________
Signature Printed Name Date
_______________________________________ _____________________________ ________________
Signature Printed Name Date
ARS § 41-1030(G) requires most Arizona government agencies to prominently print the provisions of ARS § 41-1030(B), (D), (E) and (F) on
all license applications. The following is the language in ARS § 41-1030(B), (D), (E) and (F): B. An agency shall not base a licensing decision in
whole or in part on a licensing requirement or condition that is not specifically authorized by statute, rule or state tribal gaming compact. A general
grant of authority in statute does not constitute a basis for imposing a licensing requirement or condition unless a rule is made pursuant to that general
grant of authority that specifically authorizes the requirement or condition. D. This section may be enforced in a private civil action and relief may
be awarded against the state. The court may award reasonable attorney fees, damages and all fees associated with the license application to a party
that prevails in an action against the state for a violation of this section. E. A state employee may not intentionally or knowingly violate this section.
A violation of this section is cause for disciplinary action or dismissal pursuant to the agency’s adopted personnel policy. F. This section does not
abrogate the immunity provided by section 12-820.01 or 12-820.02.
Submit the application, enclosures, and fee using the TPA Portal
(https://azinsurance.online/Upload/tpa)