Fill - Free fillable Form E-710: Application for Purchasing Group Registration: (Arizona) PDF form

Form E-710 (v. 20180619)

Phone: (602) 364-3450

Attn: Purchasing Group Registration Team

Arizona Department of Insurance

100 North 15th Avenue, Suite 261

Phoenix, Arizona 85007-2630 Email: ebowsher@azinsurance.gov

Form E-710: Application for Purchasing Group Registration

SECTION A: Applicant Identity

Department of Insurance Use:

Applicant Name:

FEIN #:

DBA Name (if applicable):

State of Domicile:

SECTION B: Contact Information

Home Office Address (cannot be P.O. Box or PMB):

City:

State:

ZIP Code:

Mailing Address:

City:

State:

ZIP Code:

Main Administrative Office Address:

City:

State:

ZIP Code:

Area Code and Phone Number:

Toll Free Phone Number:

Fax Number:

Contact Person – Name:

E-mail Address:

Title:

Phone Number:

SECTION C: Business Plan

1. Describe the business, trade, product, services, premises or operations engaged in by the Purchasing Group’s

members:

2. Describe the lines and classifications of liability insurance the Purchasing Group intends to purchase:

SECTION D: Applicant Declaration. Carefully read the questions below and answer

each one “yes” or “no”. If “no”, attach detailed explanation:

YES (x) NO (x)

1. One of the purposes of the Purchasing Group is the purchase of liability insurance on a group

basis. (ARS §20-2401(9)(a))

2. The Purchasing Group intends to purchase liability insurance only for its members and only to

cover their similar or related liability exposure. (ARS §20-2401(9)(b))

3. The Purchasing Group will not purchase insurance from a risk retention group that is not

chartered in a state or from an insurer which is not admitted in the state in which the

purchasing group is located, unless the purchase is effected through a licensed insurance

producer. (ARS §20-2408(A))

Reset

Applicant Name:

PAGE 2 of 2

Form E-710: Application for Purchasing Group Registration (v. 20180619)

4. The purchasing group agrees that if liability insurance is obtained from an insurer that is not

admitted in this state or a risk retention group that it shall inform each of the members of t

oup which have a risk resident or located in this state that the risk is not protected by an

insurance insolvency guaranty fund in this state and that the risk retention group or the insurer

may not be subject to all insurance laws and rules of this state. (ARS §20-2408(C))

5. The Purchasing Group has completed the NAIC Uniform Consent to Service of Process

and Resolutions Authorizing Appointment of Attorney Form 12 and has designated t

rizona Director of Insurance as its agent solely for the purpose of receiving service of legal

documents or process. (ARS §20-2407(B))

6. The Purchasing Group will promptly submit any revisions to the information contained in this

registration application. (15 USC §3903(d)(2))

SECTION E: Required Enclosures

1. ENCLOSE the NAIC Uniform Consent to Service of Process and Resolutions Authorizing Appointment of

ttorney Form 12

2. ENCLOSE the Purchasing Group List of Insurers and Agents Form E-711

3. ENCLOSE documentation that verifies the state of domicile. (ARS §20-2401)

(a)

or a corporation, the state in which the purchasing group is incorporated.

(b)

or an unincorporated entity, the state of its principal place of business.

SECTION F: AFFIDAVIT of an officer of the applicant authorized by the applicant to verify the facts stated in the

application.

I, ________________________________________________________________ (name of affiant) being duly sworn,

depose and say under oath that I am the

________________________________________________________________ (title) of

________________________________________________________________ (Applicant Name)

AND that I have authority to bind the registrant,

AND that all information provided in all sections of this application and in all enclosures herewith are true and correct to

the best of my knowledge and belief.

____

___________________________________________ ________________

Signature Date

SECTION G: APPLICATION CONTACT PERSON

Application Contact Person – Name:

E-mail Address:

Title:

Phone Number:

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.

Fill Online, Printable, Fillable, Blank Form E-710: Application for Purchasing Group Registration: (Arizona) Form

Related forms

Fillable Form E-710: Application for Purchasing Group Registration: (Arizona)

Fill Online, Printable, Fillable, Blank Form E-710: Application for Purchasing Group Registration: (Arizona) Form

Related forms

First 20 documents completely FREE!