Licensing Section
Arizona Department of Insurance
100 North 15
th
Avenue, Suite 102, Phoenix, Arizona 85007-2624
Phone: (602) 364-4457 | Toll-free: (877) 660-0964
Web: https://insurance.az.gov | E-mail: Licensing@azinsurance.gov
L-193 Rev. 20180618
Form L-193: CERTIFICATE OF ASSUMED BUSINESS NAME
Make sure no one else is using a name that is substantially similar to the name you wish to use:
• Use the “LICENSE SEARCH” feature on the Department of Insurance web site
(https://insurance.az.gov) to see if another licensee is using a substantially similar name.
• Use the “eCorp” search option on the Arizona Corporation Commission’s web site
(http://ecorp.azcc.gov) to see if anyone has registered a substantially similar name.
1. If this certificate is for an individual or business that already has an Arizona
insurance license, enter the license number; otherwise leave blank. ►
2. Is the person seeking to use the assumed business name a BUSINESS ENTITY or an INDIVIDUAL?
BUSINESS ENTITY (Go to #3) INDIVIDUAL (Skip #3; go to #4)
3. Enter the (genuine/legal) name of the business entity (skip #4 and go to #5)
4. Genuine/legal (“FULL”) Last Name
5. If you want an existing assumed name removed from your license, enter that name here
6. If you want an assumed name added to your license, enter that name here.
ACKNOWLEDGMENT AND CERTIFICATION
As the person conducting or intending to conduct insurance under the assumed name on this Certificate, or as the
designated responsible producer (DRP) of a firm or corporation (business entity) that is conducting or intends to conduct
insurance under the assumed name on this Certificate, by my signature below, I hereby acknowledge and certify that:
1) This form does not constitute an insurance license. If I establish and intend to sell, solicit or negotiate insurance
through a firm or corporation that uses the name shown on this form, I understand that the firm or corporation must
apply for and be issued an Arizona insurance license prior to conducting insurance business in Arizona.
2) The Director of Insurance may deny the use of an assumed business name, require the use of a different assumed
business name or require the use of an assumed business name if either,
• the name is so similar to that of any firm, corporation or other entity already licensed or using a duly filed assumed
name that use of the name pursuant to this Certificate may cause uncertainty or confusion, or,
• the name would tend to deceive or mislead the public as to the nature of the business that is or will be conducted.
3) The licensee must notify the Department of Insurance in writing within 30 days after any material change to the
information provided on this form.
4) Filing this certificate does not legally reserve the assumed business name as a trade name.*
*NOTE: You can reserve a trade name with the Arizona Secretary of State. If you received a Trade Name Certificate
from the Arizona Secretary of State, please attach it to this Certificate. If you do not register your name with the
Arizona Secretary of State and we receive a license application from a person whose genuine name or trade name
is substantially similar to your assumed name, we may require you to stop using the assumed name.
Signature:
___________________________________________________________
Date: ______________________
