Fillable Form L-CRT: LETTER OF CERTIFICATION REQUEST: (Arizona)

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Form L-CRT: LETTER OF CERTIFICATION REQUEST: (Arizona)

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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
Form L-CRT (Rev 06/2019)
Form L-CRT: LETTER OF CERTIFICATION REQUEST
Instead of requesting a Letter of Certification, we recommend that the public and the insurance
industry conduct a “license search,” available at no charge from the Department of Insurance web
site (https://insurance.az.gov
). The online search provides the most up-to-date information.
To request a Letter of Certification, complete this form; enclose a check or money order for the
“total due” calculated in Section 2; and, either enclose a self-addressed, stamped envelope or
indicate that you will be picking up the document(s) when they are ready.
SECTION 1. Information about the licensee
AZ Insurance License Number:
NOTE: You can only request a Letter of Certification for an
Arizona-resident
licensee.
For an INDIVIDUAL:
Last Name:
First Name:
Middle Name:
For a BUSINESS ENTITY:
Full Name:
SECTION 2: Information about your request
How many Letters of Certification would you like to receive concerning
the licensee named in Section 1?
Quantity:
Fee per Letter of Certification:
$3.00
AMOUNT DUE (must be submitted with this form):
SECTION 3: Letter of Certification delivery method
Send by mail. I have provided a self-addressed stamped envelope.
I will pick up in person. Call when ready.
SECTION 4: Information about you (the requester)
Area Code and Phone Number:
Address
City:
State:
ZIP Code:
E-mail Address:
If you mailed this form, please allow one to three weeks for processing
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Form L-CRT: LETTER OF CERTIFICATION REQUEST: (Arizona)

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Completed 12 August 2020

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