Form SL-112 (v. 20180619)
Phone: (602) 364-3986
Financial Affairs Division
Arizona Department of Insurance
100 North 15th Avenue, Suite 261
Phoenix, Arizona 85007-2630 Email: ccook@azinsurance.gov
Form SL-112: Application for Domestic Surplus Lines Insurer Designation
Pursuant to ARS § 20-407.01, the director may designate an authorized insurer as a domestic surplus lines insurer if the
applicant meets all the following conditions:
1. The applicant either ►holds a Certificate of Authority as an Arizona-domiciled insurer; or, ►meets all requirements to
be issued a Certificate of Authority as an Arizona-domiciled insurer and submits with this form a Uniform Certificate of
Authority Application (UCAA) with additionally required materials;
2. The applicant possesses minimum capital and surplus of at least $15 million; and,
3. The applicant’s board of director’s approves a resolution to be designated an Arizona domestic surplus lines insurer.
Once designated, a domestic surplus lines insurer is restricted to only writing surplus lines insurance.
SECTION A: Applicant Information
Department of Insurance Use:
SECTION B: Contact Information
SECTION C: Required Enclosures
1. ENCLOSE the duly executed resolution of the applicant’s board of directors to be designated an Arizona domestic
surplus lines insurer.
2. ENCLOSE a balance sheet for the most recently completed calendar quarter that demonstrates the applicant
possesses minimum capital and surplus of at least $15 million.
3. Does the applicant currently hold a Certificate of Authority in Arizona? YES NO
If YES, ENCLOSE the current original Arizona Certificate of Authority and a check made payable to the Arizona
Department of Insurance in the amount of $195.00.
If NO, FILE a UCAA Primary application with all additionally required materials electronically through the UCAA
website and ENCLOSE a filing confirmation page. http://www.naic.org/industry_ucaa.htm
SECTION D: ATTESTATION AND CERTIFICATION of an officer of the applicant authorized by the applicant to
verify the facts stated in the application (“Authorized Officer”).
By signing this form, the Authorized Officer
1. Attests and certifies that all information contained in the application and any attachments, enclosures and
supplements thereto, are true, complete and accurate, to the best of the Authorized Officer’s knowledge and belief.
2. Certifies that upon designation as an Arizona domestic surplus lines insurer, the applicant shall only write surplus
lines insurance and shall comply with the laws of the State of Arizona that pertain to Arizona domestic surplus lines
insurers.
Signature of Authorized Officer:
_____________________________________
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.
