Fillable Form E-801: Motor Vehicle Dealers Notice of Intent: (Arizona)

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Form E-801: Motor Vehicle Dealers Notice of Intent: (Arizona)

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Form E-801 (v. 20180619)
Phone: (602) 364-3450
Attn: Service Company Permit Team
Arizona Department of Insurance
100 North 15th Avenue, Suite 261
Phoenix, Arizona 85007-2630
Email: ebowsher@azinsurance.gov
Form E-801: Motor Vehicle Dealer’s Notice of Intent
SECTION A: Motor Vehicle Dealer Identity
Department of Insurance Use:
Motor Vehicle Dealer Name:
FEIN #:
DBA Name (if applicable):
State Incorporated/Organized:
Motor Vehicle Dealer License Number:
SECTION B: Motor Vehicle Dealer Information
Motor Vehicle Dealer Address:
City:
State:
Area Code and Phone Number:
Toll Free Phone Number:
Fax Number:
Motor Vehicle Dealer Contact Person – Name:
E-mail Address:
Title:
Phone Number:
SECTION C: Service Company (Administrator) Information
Service Company Name:
FEIN #:
Service Company Address:
City:
State:
Service Company Contact Person – Name:
E-mail Address:
Title:
Phone Number:
SECTION D: Motor Vehicle Service Contract Program(s)
Contract Name:
Form Number:
Edition Date:
Contract Name:
Form Number:
Edition Date:
Contract Name:
Form Number:
Edition Date:
Contract Name:
Form Number:
Edition Date:
Contract Name:
Form Number:
Edition Date:
Contract Name:
Form Number:
Edition Date:
Contract Name:
Form Number:
Edition Date:
Reset
Motor Vehicle Dealer Name:
PAGE 2 of 2
Form E-801: Motor Vehicle Dealer’s Notice of Intent (v. 20180619)
SECTION E: Mechanical Reimbursement Policy or Bond
Insurer Name:
Policy Number:
Expiration Date:
Insurer Name:
Policy Number:
Expiration Date:
SECTION F: AFFIDAVIT of an officer of the motor vehicle dealer authorized by the motor vehicle dealer to verify the
facts stated in the notice of intent. ARS § 20-1095.07 and AAC R20-6-408(F)
I, ________________________________________________________________ (name of affiant) being duly sworn,
depose and say under oath that I am the (select only one)
chief executive officer;
chairman of the board of directors,
other person having power of attorney (notarized power of attorney included)
of ________________________________________________________________ (Applicant)
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,
AND that information contained in and with this application is consistent with information reflected in Arizona Corporation
Commission records;
AND that I understand any misrepresentation or omission of a material fact in this application or the enclosures herewith
is a ground for denial or revocation of the Permit;
AND that I am familiar with the insurance laws and regulations of the State of Arizona, including but not limited to
Arizona Revised Statutes Title 20, Chapter 4, Article 11 (ARS § 20-1095 et seq.) and Arizona Administrative Code R20-
6-408, and I shall comply with the laws and regulations of the State of Arizona.
_______________________________________________ ________________
Signature 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.
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Form E-801: Motor Vehicle Dealers Notice of Intent: (Arizona)

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Completed 12 August 2020

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