Fill - Free fillable Form E-811: Renewal of Service Company Permit: (Arizona) PDF form

Form E-811 (v. 20180810)

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-811: Renewal of Service Company Permit

SECTION A: Applicant Identity

Department of Insurance Use:

1 Applicant must be registered in good standing with the Arizona Corporation Commission

(“ACC”). 2 Information on the ACC web site (http://ecorp.azcc.gov/Search) must be up to

date and consistent with information reported on this application. 3 You must update any outdated information with the

ACC before submitting this application to the Department of Insurance. ARS § 20-1095.03(A), AAC R20-6-407(C).

Applicant Name:

FEIN #:

DBA Name (if applicable):

State Incorporated/Organized:

Type of Entity:  Association  Corporation  LLC  Partnership  Sole Proprietorship

 Other ______________________________________________________________________

SECTION B: Contact Information

Arizona Address:

City:

State:

ZIP Code:

Home Office Address (Cannot be P.O. Box or P.M.B.):

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:

Consumer Contact Person – Name:

E-mail Address:

Title:

Phone Number:

SECTION C: Summary of Financial Position. Provide the following information from the most recent

financial statements included with this application (see Section E, Item 3):

1. (INCOME STATEMENT) Net Income

2. (BALANCE SHEET) Current Assets

3. (BALANCE SHEET) Current Liabilities

4. (BALANCE SHEET) Working Capital

5. (BALANCE SHEET) Owner’s Equity

6. Fiscal Year End (i.e. 6/30 or 12/31)

7. Additional financial position requirements (if this space is not blank):

A response to Section C, Item 1, 4 or 5 was negative. You must ENCLOSE a description of the applicant’s plan to

become financially solvent, such as capital infusion, parental guarantees, etc. For plans that involve a third party,

ENCLOSE a letter from the third party that describes the investments or guarantees the third party is providing to the

applicant, and ENCLOSE financial statements (balance sheet and income statement) of the third party.

IMPORTANT!

Reset

Applicant Name:

PAGE 2 of 3

Form E-811: Renewal of Service Company Permit (v. 20180810)

SECTION D: Applicant Declaration

YES (x)

NO (x)

1. The service company’s service contract, application, claim forms, brochures, other advertising

material, and other forms have been filed through the System for Electronic Rate and Form

Filings (SERFF). If NO, see AAC R20-6-407(E).

2. The service company has had or has pending suspensions, revocations or other disciplinary

or rehabilitative actions against it in Arizona or any other jurisdiction? If YES, see Section E, Item 6.

3. A deposit in favor of the State of Arizona in the amount of $100,000 is on file with or for the

benefit of the Director of Insurance. (ARS 20-1095.04) If NO, provide enclosures in Section E, Item 2.

SECTION E: Required Enclosures

1. ENCLOSE payment of the $300 fee, made payable to Arizona Department of Insurance

2. A deposit in favor of the State in the amount of $100,000 to be filed with or for the benefit of the Director OR

a mechanical reimbursement (contractual liability) insurance policy issued by an insurer authorized to do

business in the State by ONE of the following methods:

a. Surety bond: Must be issued by an insurer authorized in Arizona to offer surety bonds; may include individual

bonds, schedule or blanket bonds. ENCLOSE Form E-857 and an Attorney-in-Fact.

b. Marketable security: ENCLOSE one Custody Agreement (Form E-003) and one Form E-125.

c. Mechanical reimbursement (contractual liability) insurance policy: ENCLOSE confirmation that the

policy is in force.

3. ENCLOSE copies of the most recent income statement and balance sheet as of the end of the service

company’s most recent fiscal year, sworn to and certified by the owner, duly elected officers, or a certified public

accountant. AAC R20-6-407(G)

4. Arizona law and rule (ARS § 20-1095.03(A)(2) and AAC R20-6-407(C)(2)(e)) define “individuals responsible for

the service company’s affairs as including:

 All members of the board of directors/trustees, members of the executive committee or any other governing

board of the committee; and,

 If applicant is a corporation, all officers and all shareholders that directly or indirectly own 25% or more of the

voting securities of the applicant if a corporation; and,

 If applicant is a partnership or association, all partners.

As it relates to individuals responsible for the service company’s affairs:

a. ENCLOSE Form E-800-B listing the names and titles of all “individuals responsible for the service company’s

affairs.” For each individual, indicate whether an NAIC Biographical Affidavit Form 11 was previously submitted

to the Arizona Department of Insurance by the applicant.

b. ENCLOSE NAIC Biographical Affidavit Form 11 for each individual listed on Form E-800-B for whom a Form

11 was not previously submitted by the applicant. .

IMPORTANT! The Department will investigate information provided and may deny a permit if the applicant

fails to provide complete and truthful information about itself and the individuals responsible for the service

company’s affairs.

5. Did any NAIC Biographical Affidavit Form 11 contain a “Yes” response to one or more question in Item 11?

ARS § 20-1095.03(A)(2) and AAC R20-6-407(C)(2)(e)

 YES. ENCLOSE a copy of the complaint and the filed adjudication or settlement for each matter.

 NO

Applicant Name:

PAGE 3 of 3

Form E-811: Renewal of Service Company Permit (v. 20180810)

6. OTHER REQUIRED ENCLOSURES based on responses in other parts of this application form:

You responded YES to Section D, Item 2. You must ENCLOSE a signed statement detailing all incidents including

names of all parties involved, dates and locations, the names and localities of any courts and administrative agencies

involved, the disposition of each matter, whether the conviction, plea or finding was for a felony or open-ended charge;

AND, you must ENCLOSE copies of any and all indictments, complaints, plea agreements, orders of conviction, notices

of hearing or trial, sentencing orders, suspension/revocation orders and any other information that relates to each

matter. If copies are not available, you must provide as a part of this application a letter from the clerk of the pertinent

court or the official involved stating the records are not available and the reason.

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

application. AAC R20-6-407(C)(1)(g)

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-

6-407, and I shall comply with the laws and regulations of the State of Arizona.

_______________________________________________ ________________

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.

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Fillable Form E-811: Renewal of Service Company Permit: (Arizona)

Fill Online, Printable, Fillable, Blank Form E-811: Renewal of Service Company Permit: (Arizona) Form

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