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

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

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Form E-700 (v. 20180727) Page 1 of 2
Attn: Surplus Lines Team Arizona
Department of Insurance
100 North 15th Avenue, Suite 261
Phoenix, Arizona 85007-2630
Phone: (602) 364-3450
Email: ebowsher@azinsurance.gov
Form E-700: Certificate of Surplus Lines Broker
SECTION A: Entity Type
Department of Insurance Use:
Foreign Alien Lloyd’s Association Insurance Exchange Syndicate
Each syndicate must file an annual financial statement in a form prescribed by the NAIC.
SECTION B: Surplus Lines Insurer Information
Insurance Exchange Name | Name:
NAIC #:
Exchange Syndicate Name | DBA Name
U.S. State/Territory or Non-US
Country Incorporated/Organized:
Mailing Address:
City:
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 will forward
legal process against the insurer.
Name:
Phone Number:
Physical Street Address (must not be P.O. box):
City:
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:
Title:
Phone Number:
SECTION E: Surplus Lines Broker Declaration
1.
Syndicate of an insurance exchange – Enter the US state where the insurer is authorized to
transact insurance on an admitted or surplus-lines basis. ARS § 20-413(E)
2.
Insurance exchange – The insurance exchange must possess capital and surplus of at least
$50,000,000, and each syndicate of the insurance exchange must possess capital and
surplus of at least $5,000,000. Enter the amount of the insurance exchange’s capital and
surplus AND enter the amount of the syndicate’s capital and surplus. ARS § 20-413(E)
Reset
Name
DBA Name
Form E-700: Certificate of Surplus Lines Broker
Form E-700 (v. 20180727) Page 2 of 2
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
Insurance exchange – The insurance exchange must maintain a deposit of at least
$2,500,000 in public custody in trust for the purpose of protecting all the insurer’s
policyholders in the U.S. Enter the amount of the deposit that the insurance exchange
maintains and the state within the U.S. that has custody of the deposit.
SECTION F: Required Enclosures
1. ENCLOSE Form E-701 completed by the
Syndicate of an insurance exchange – U.S. insurance supervisory official with whom the required trust fund is
maintained.
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
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Form E-700: Certificate of Surplus Lines Broker: (Arizona)

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Completed 12 August 2020

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