Fillable Form and Name of Insurer in subject line. (Arizona)

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Form and Name of Insurer in subject line. (Arizona)

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ARIZONA DEPARTMENT OF INSURANCE
MARKET OVERSIGHT DIVISION
Phone: (602) 364-2393
Web: https://insurance.az.gov
Propcas@azinsurance.gov
Annually, on or before April 1, insurers subject to A.R.S. §20-1621.05(C)(1) shall complete this form and
provide it to the Director of Insurance by e-mail to propcas@azinsurance.gov. Put “Credit Rate Certification
Form” and Name of Insurer in subject line. DO NOT MAIL ORIGINAL/HARD COPY DOCUMENT.
CERTIFICATION
I,
, being duly sworn, avow that I am authorized
Name of Person Completing the Form
by
NAIC #
Complete Name of Insurer
to certify to the Director of Insurance, pursuant A.R.S. § 20-1621.05(C)(1), that the rates set forth in Exhibit 1
and attached hereto: 1) do not exceed the prima facie rates established by the Director; and 2) are not
inadequate or unfairly discriminatory. Further, the rates set forth in Exhibit 1 are the actual rates currently
being applied by the aforementioned insurer. The attached rates are applicable to (check one):
Credit Property
Credit Unemployment
All information provided herein and in all attachments hereto is true and correct to the best of my knowledge
and belief.
Signature of Person Completing Form
Date
Mailing Address
City
State
Zip
Telephone Number
Email Address
SUBSCRIBED AND SWORN TO ME BEFORE THIS
DAY OF
BY
MY COMMISSION EXPIRES
Signature of Notary
Certification Form CU 1621 (v. 20190331)
Reset Form
20
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Form and Name of Insurer in subject line. (Arizona)

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Completed 12 August 2020

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