Form E-701 (v. 20180727)
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-701: Certificate of Public Supervisory Official
Department of Insurance Use:
Domestic Admitted Insurer Domestic Surplus Lines Insurer Alien Insurer
Lloyd’s Association Insurance Exchange Syndicate
SECTION B: Insurance Supervisory Official
Division/Section/Bureau Name
U.S. State/Territory
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SECTION C: Surplus Lines Insurer Information
Insurance Exchange Name | Name:
Exchange Syndicate Name | DBA Name
SECTION D: Public Supervisory Official Declaration
1. Insurance exchange syndicate– The insurance exchange is authorized to transact insurance
on an admitted or surplus-lines basis in <U.S. State>
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)
3. Lloyd’s association – The Lloyd’s association must maintain a deposit of at least
$100,000,000 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 Lloyd’s association
maintains and the state within the U.S. that has custody of the deposit.
SECTION E: Public Supervisory Official Certification
I hereby certify that I am the public official or other person having supervision over insurers in this State and that all the
information contained in this Certificate is true and correct to the best of my knowledge and belief.
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Signature Date
