L-WAV (v. 20170809)
Administrative Services Division
ARIZONA DEPARTMENT OF INSURANCE
LICENSE FEE WAIVER REQUEST
Attestation
Applicant’s Full Name (full first name, full middle name, full last name, suffix – Please print)
Type of License (and Fee to be Waived)
Adjuster ($120)
Life Settlement Broker ($250 or $500)
Producer ($120)
Surplus Lines Broker ($500 or $1,000)
Self-service Storage Agent ($120)
Bail Bond Agent ($120)
Portable Electronics Vendor ($120)
Risk Management Consultant ($120)
Temporary Producer ($120)
Life/Health Administrator ($195)
To qualify for a waiver of your license fee, you must meet all the following requirements:
1. You must be an individual. This does not apply to business entities.
2. Your family income may not exceed 200% of the applicable federal poverty level as
published each year in the Federal Register by the US Department of Health and Human
Services (see: https://aspe.hhs.gov/poverty-guidelines for current federal poverty levels).
3. You cannot have previously applied in Arizona, either as a resident or nonresident,
regardless of whether you were ever issued a license in Arizona, for the type of license for
which you are requesting a fee waiver.
Attestation and Cetification
By signing below:
1. I attest that I read and understood the foregoing;
2. I certify under penalty of denial, suspension or revocation of any license issued and
under any other penalties, including restitution to the State of Arizona, including but not
limited to the Arizona Department of Insurance,
that (a) my family income does not
exceed 200% of the applicable federal poverty level; AND, (b) I have never applied with
the State of Arizona for the Type of License indicated on this form;
3. I understand the State of Arizona and its agencies, including the Arizona Department of
Insurance, may obtain information from the Arizona Department of Revenue and other
sources for the purposes of verifying I qualify for the fee waiver.
4. I acknowledge that by submitting this form, it becomes part of my license application. I
understand that providing incorrect, misleading, incomplete or materially untrue
information on a license application is a violation of Arizona law, which could result in
the denial, suspension or revocation of licenses, in the imposition of civil penalties, and
in other administrative and legal consequences.
Date
Applicant Signature
