Fillable Form E-700: Certificate of Surplus Lines Broker: SECTION (Arizona)

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Form E-700: Certificate of Surplus Lines Broker: SECTION (Arizona)

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Country of origin: US
File type: PDF

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Form E-700: Certificate of Surplus Lines Broker
SECTION A: Entity Type
Department Use:
Foreign
Alien
Lloyd’s Association
Insurance Exchange Syndicate
SECTION B: Surplus Lines Insurer Information
FEIN #:
Name
NAIC #:
DBA Name
U.S. State/Territory or Non-US
Country Incorporated/Organized:
Mailing Address:
City:
State:
ZIP Code:
SECTION C: Service of Process Information
Enter information for the person to whom, pursuant to A.R.S. § 20-419, the Director of Insurance and
Financial Institutions will forward legal process against the insurer.
Phone Number:
Physical Street Address (must not be P.O. box):
City:
State:
ZIP Code:
SECTION D: Surplus Lines Broker Information
Only an Arizona-licensed resident or non-resident surplus lines broker may file this Certificate.
Broker Name:
AZ Insurance License #:
Contact Person – Name:
E-mail Address:
Phone Number:
SECTION E: Surplus Lines Broker Declaration
1.
2.
Form E-700 (v 20201111) Page 1 of 2
Name
DBA Name
Reset
Form E-700: Certificate of Surplus Lines Broker
3. The Insurer maintains a deposit in public custody in trust for the purpose of protecting all of
the Insurer’s policyholders in the United States pursuant to ARS § 20-413
SECTION F: Required Enclosures
1. INCLUDE Form E-701 completed by the
SECTION G: Surplus Lines Broker Attestation
If the surplus lines broker is a business entity, this attestation must be executed by the designated responsible licensed
producer (“DRLP”) of the broker.
All information contained in this Certificate is true and correct to the best of our knowledge and belief.
Signature of Broker Printed Name of Broker or DRLP Date
Send the application documents to erica.bowsher@difi.az.gov
.
Form E-700 (v 20201111) Page 2 of 2
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Form E-700: Certificate of Surplus Lines Broker: SECTION (Arizona)

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Completed 1 July 2022

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