Fillable NAIC Uniform Application for Individual Producer License/Registration (Arizona)

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NAIC Uniform Application for Individual Producer License/Registration (Arizona)

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Page 1 of 6 AZ Individual Application Instructions (v. 20180618)
INSTRUCTIONS
NAIC Uniform Application for
Individual Producer License/Registration
LICENSING
FOR USE IN APPLYING FOR AN INITIAL INSURANCE LICENSE OR ADDING A LINE OF AUTHORITY FOR AN INDIVIDUAL.
USE THE NATIONAL INSURANCE PRODUCER REGISTRY (www.nipr.com) instead of a paper
application form to apply for a license online. NIPR applications are processed more quickly.
DO NOT USE THIS APPLICATION…
• To renew a license. Use www.nipr.com to renew your license.
• To apply for a license as a health insurance exchange navigator or certified application
counselor. Use Form L-NAV to apply for this license authority.
IF YOU USE A PAPER APPLICATION INSTEAD OF NIPR.COM TO APPLY FOR YOUR LICENSE:
Carefully read instructions: You may need to submit additional forms or documents with
your application. If your application does not contain all the necessary forms or documents, or
is otherwise not complete, the application will be returned as deficient.
Complete this form on your computer. Save and print the completed form to submit with
other required documents and fees. To use the form, you must have Adobe Acrobat Reader
software.
Be sure to sign and date the application in the Applicant’s Certification and Attestation
section.
Mail or deliver the completed application with all required documents and fees to:
INSURANCE LICENSING SECTION
SUITE 102
100 NORTH 15
TH
AVENUE
PHOENIX, AZ 85007-2624
KEEP THESE INSTRUCTIONS:
DO NOT
return them with your license application.
QUESTIONS?
Before calling the Department of Insurance, look for answers on the PRODUCERS page of the
department’s web site (https://insurance.az.gov). For questions not addressed on our web site, contact
the Insurance Licensing Section:
E-mail: Licensing@azinsurance.gov
Phone: 602-364-4457, or 877-660-0964 if calling long-distance within Arizona.
Print Instructions
Go to form
Page 2 of 6 AZ Individual Application Instructions (v. 20180618)
1. FEES (for a new license OR to add authority to an existing license):
Fees are NON-REFUNDABLE and are not prorated [A.R.S. § 20-167(B)].
Make your check or money order payable to INSURANCE LICENSING SECTION.
Insurance License Fee ...............................
$120.00
One fee per License Class/Type requested ..
• Adjuster
• Bail Bond Agent
• Insurance Producer
• Portable Electronics Vendor
• Rental Car Agent
• Risk Management Consultant
• Self Service Storage Agent
• Temporary Producer
Surplus Lines Broker License Fee ............
• Surplus Lines Broker
• Mexican Insurance Surplus Lines Broker
$500.00 to add authority to an existing
license that expires in two years or less;
OR
$1,000.00 for authority that expires in more
than two years.
Life Settlement Broker License Fee ..........
$250.00 to add authority to an existing
license that expires in two years or less;
OR
$500.00 for authority that expires in more
than two years.
Navigator and/or Certified Application
Counselor ....................................................
$0.00
Fingerprint Card Processing Fee ..............
$22.00
The fingerprint card processing fee
is separate from the fee that a fingerprinting service will charge to apply
fingerprints to a fingerprint card. [A.R.S. §§ 20-142(E) and 41-1750(G)(2)]
2. LICENSE TERM:
• The following License Class/Types will utilize the same license terms/expiration dates:
Insurance Producer
Life Settlement Broker
Navigator
Certified Application Counselor
Surplus Lines Broker
• The following License Class/Types will have independent license terms/expiration dates:
Adjuster
Bail Bond Agent
• A new License Class/Type grouping expires on the last day of the licensee’s birth month
between three and four years from the date of issuance.
• License authority added to an existing License Class/Type grouping expires on the same date
as existing authority.
Page 3 of 6 AZ Individual Application Instructions (v. 20180618)
3. If you answer “YES” to one or more of the questions in Section IV, include:
a. A signed statement describing in detail all incidents including
• names of all parties involved,
• dates and locations,
• the names and localities of any courts and/or administrative agencies involved,
• the disposition of each matter,
• whether the conviction, plea or finding was for a felony or open-ended charge;
and
b. Copies of any and all indictments, complaints, plea agreements, orders of conviction, notices
of hearing or trial, sentencing orders, suspension/revocation orders and any other information
which relates to each matter. If copies are not available, you must provide as a part of this
application, a letter from the clerk of the pertinent court or the official involved stating the
records are not available and the reason.
4. ASSUMED NAME (OR DBA): While conducting insurance business, you must use your legal
name or an acceptable assumed name. To use an assumed name, submit Form L-193. A
licensee should also consider protecting the name against use by others by applying with the
Arizona Secretary of State for a Trade Name Certificate (www.sosaz.gov, 602-542-6187).
The Violent Crime Control and Law Enforcement Act of 1994
convicted of any criminal felony involving dishonesty, breach of trust or a violation of the Act
appropriate state insurance regulatory official. 18 U.S.C. § 1033.
obtain the specific written consent may be subject to federal criminal prosecution. There is no
prohibits any person or entity from willfully permitting a prohibited person, as described above,
from engaging in the business of insurance and the Act subjects such a person or entity to
5. IF YOU ARE APPLYING FOR A NONRESIDENT LICENSE:
• You must hold an active resident license in your home state (a US state or territory) EXCEPT:
If you are an insurance adjuster or a portable electronics insurance adjuster from a state
that does not issue adjuster licenses, you must provide with your application, Form L-152
(see “Licensing Eligibility Requirement”) and a fingerprint card (see “Fingerprints”).
If you are an insurance adjuster (not portable electronics insurance adjuster) and your
home state does not issue adjuster licenses, you must also pass the Arizona adjuster
examination (see “Examination Requirement”).
• Your resident state license will be electronically verified and must be in good standing.
• If you are applying for license authority that you hold in your home state that is not shown on
the application, check the box (on the fillable form) and enter the line of authority on the line
entitled, “Other.”
6. IF YOU ARE APPLYING FOR A RESIDENT LICENSE:
• Principal Location:
To apply as an Arizona resident, you must maintain your principal place of business (location
you are physically at while conducting business) or your principal place of residence within
Arizona.
Page 4 of 6 AZ Individual Application Instructions (v. 20180618)
• Licensing Eligibility Requirement:
If you do not already hold an Arizona-resident license and you are either a resident of Arizona
or a non-resident adjuster from a state that does not issue adjuster licenses, you must submit
Form L-152.
• Examination Requirement:
Arizona residents must pass an insurance license examination before applying for the
following license authority:
Insurance producer (applies to property, casualty, life, accident/health, crop and
personal lines only)
Surplus lines broker
Bail bond agent
Insurance adjuster — A non-resident from a state that does not license insurance
adjusters must also pass Arizona’s insurance adjuster examination.
For examination information and scheduling, visit Prometric’s Internet web site at
www.prometric.com/arizona.
Relocating to Arizona: If you are moving to Arizona from another state, you may submit a
“Clearance Letter” from your previous home state in lieu of passing Arizona’s insurance
license examination (see EXCEPTION noted below).
The Department of Insurance must
receive your Clear
ance Letter and your complete license application (including all required
forms and fees) within 90 days after your license in your previous home state is cancelled.
EXCEPTION to using a Clearance Letter in lieu of passing an Arizona insurance
examination:
If you failed Arizona’s insurance license examination for the desired line of
authority four times within the 12-
month period, you must wait 12 months after the last
examination failure to apply for the line of authority, even if you become licensed as a resident
of another state, cancel the license in the other state and return to Arizona with a Clearance
Letter from the other state.
• Fingerprints:
If you are an Arizona resident who does not already hold an Arizona-resident insurance
license, or if you are a non-resident adjuster from a state that does not license adjusters, you
must complete the following procedures:
a. Submit a sealed envelope containing the completed fingerprint card (Form FD-258) and
Form L-FPV in accordance with the procedures shown on Form L-FPV.
b. Ensure the fees you submit with your application include the FBI Fingerprint Processing
Fee for each card you submit.
We strongly recommend that you use a professional fingerprinting service that scans your
fingerprints with LiveScan technology and prints your fingerprints on a fingerprint card.
LiveScan equipment typically provides more legible fingerprints. Fingerprints that are
illegible will be rejected and a replacement fingerprint card will need to be submitted.
c. The fingerprinting technician must carefully follow instructions on Form L-FPV (Fingerprint
Verification Form), which will require you to show a valid, unexpired government-issued
photo ID. Information on your ID must be current and must match the information entered
on the fingerprint card.
Page 5 of 6 AZ Individual Application Instructions (v. 20180618)
d. The fingerprinting technician will place the completed card and Form L-FPV in a sealed
envelope and will write his/her name along the envelope seal. DO NOT open or fold the
envelope containing the card or the card will be rejected.
e. Send or deliver to the Insurance Licensing Section, the unopened and not-folded fingerprint
card envelope with the fingerprint card processing fee and other license application
materials in a larger envelope.
Fingerprints submitted with an insurance license application will be used to check
FBI criminal history records:
If you have a criminal history record, the Department of Insurance will
provide you the
opportunity to complete or challenge the accuracy of the information in the record and a
reasonable amount of time to correct or complete the record (or decline to do so) before a
license is denied based on the criminal history record. The
procedures for changing,
correcting or updating your FBI criminal history record are set forth in Code of Federal
Regulations (CFR) Title 28, Sections 16.30 through 16.34. Information on how to review
and challenge an FBI criminal history record is available on the FBI Web site at www.fbi.gov
(under Criminal History Summary Checks) or by calling (304) 625-5590.
To obtain a copy of your Arizona criminal history record in order to review/update/correct
the record, you can c
ontact the Arizona Department of Public Safety (ADPS) Criminal
History Records Unit at (602) 223-
2222. Information concerning the DPS review and
challenge process is available on the ADPS Web site, at www.azdps.gov.
f. Application for consent to engage in the business of insurance under
18 U.S.C. § 1033: An applicant or any person employed by the applicant who proposes to
conduct insurance business and who has been convicted of an 18 U.S.C. § 1033 offense
must complete an Arizona Application for Consent to Engage in the Business of Insurance
Under 18 USC § 1033, which is accessible on the PRODUCERS page of the Department
of Insurance Web site (insurance.az.gov).
7. IF YOU ARE APPLYING FOR A BAIL BOND AGENT LICENSE:
a. Submit a $10,000 surety bond using Form L-195. Include the surety’s power of attorney and
maintain throughout the term of the license.
b. Include Form L-BBAA
A bail bond agent may not employ or assist in the employment of any person who has been
convicted in any jurisdiction of:
ANY felony,
ANY theft conviction (misdemeanor, felony etc.) or;
ANY crime (misdemeanor, felony etc.) involving carrying or the possession of a deadly
weapon or dangerous instrument. A.R.S. § 20-341.03(A)(9).
8. IF YOU ARE APPLYING FOR A SURPLUS LINES BROKER LICENSE:
• To transact surplus lines insurance for an insured whose home state is within this state, you
must possess a surplus lines broker license issued by the Arizona Department of Insurance.
ARS § 20-411(A).
• If you will only be selling, soliciting or negotiating alien insurance for coverage in Mexico
(pursuant to ARS § 20-422), you may apply for a Mexican Insurance Surplus Lines Broker
license instead of a Surplus Lines Broker license.
Page 6 of 6 AZ Individual Application Instructions (v. 20180618)
9. IF YOU ARE APPLYING FOR A RISK MANAGEMENT CONSULTANT LICENSE:
• Include written authorization from the political subdivision (city/town/county) with which you are
employed.
A.R.S. § 41-1030(G) requires most Arizona government agencies to prominently print the
provisions of A.R.S. § 41-1030(B), (D), (E) and (F) on all license applications. The following is the
language in A.R.S. § 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.
THE ARIZONA DEPARTMENT OF INSURANCE IS AN EQUAL EMPLOYMENT OPPORTUNITY AGENCY THAT
COMPLIES WITH THE AMERICANS WITH DISABILITIES ACT ("ADA”) OF 1990. PERSONS WITH DISABILITIES MAY
REQUEST ACCOMMODATION BY CONTACTING THE ADA COORDINATOR AT 602-364-3471. REQUESTS SHOULD
BE MADE AS EARLY AS POSSIBLE TO ALLOW TIME FOR THE DEPARTMENT TO MAKE APPROPRIATE
ARRANGEMENTS.
Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please
reference the National Insurance Producer Registry web site at www.nipr.com.
© 2014 National Association of Insurance Commissioners
Page 1 of 5
Uniform Application for
Individual Producer License/Registration
(Please Print or Type)
Demographic Information
Soc. Security Number If assigned, National Producer Number (NPN)
If applicable, FINRA Individual Central Registration Depository (CRD)
Number
Last Name JR./SR. etc First Name Middle Name
Date of Birth
(month) ___ (day) ___ (year)____
Residence/Home Address (Physical Street) City State Zip Code Foreign Country
Home Phone Number
( ) -
Individual Applicant Email
A
ddress:
Gender (Circle One)
Male Female
Are you a Citizen of the United States? (Check One)
Yes No (If No, of which country are you a citizen?)
(If NO, and this is an application for a Resident License, you must supply proof of eligibility to
work in the U.S.)
Business Entity Name
Business Address (Physical Street) P.O. Box City State Zip Code Foreign Country
Business Phone Number (include
extension)
( ) -
Business Fax Number
( ) -
Business E-Mail Address Business Web Site Address
Applicant’s Mailing Address P.O. Box City State Zip Code Foreign Country
a. List any other assumed, fictitious, alias, maiden or trade names which you have used in the past.
b. List any trade names under which you are currently doing business or intend to do business.
(May be subject to state approval)
A
g
enc
y
or Business Entit
y
Affiliations
List your Insurance Agency Affiliations: (Complete only if the applicant is to be licensed as an active member of the business entity)
FEIN ________________________ NPN ___________________ Name of Agency ___________________________________________________________
FEIN ________________________ NPN ___________________ Name of Agency ___________________________________________________________
FEIN ________________________ NPN ___________________ Name of Agency ___________________________________________________________
Employment History
Account for all time for the past five years. Give all employment experience starting with your current employer working back five years. Include full and part-time
work, self-employment, military service, unemployment and full-time education.
From To
Month Year Month Year
Position Held
Name
City State Foreign Country
Name
City State Foreign Country
Name
City State Foreign Country
Name
City State Foreign Country
(State Use)
7
65
29
15
13 16
25
26
24
35
27
36
34
1
2
4
22
21
20
19
18
28
30
31
32
33
Check appropriate boxes for license requested.
Resident License
Non-Resident License
• Identify Home State: ___ Home State License #: _________
New Application
Additional Line of Authorit
y
3
8
9
10
11
12
17
23
(Check one)
Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please
reference the National Insurance Producer Registry web site at www.nipr.com.
© 2014 National Association of Insurance Commissioners
Page 2 of 5
Uniform Application for
Individual Producer License/Registration
Applicant Name: _________________________________________________
Jurisdiction and Type of License Requested
Next to each jurisdiction, check the license type(s) and line(s) of authority for which you are applying.
License Types:
A – Agent
B – Broker
P - Producer SLP – Surplus Lines Producer
Lines of Authority:
V – Variable
Life/Variable Annuity
L – Life
H – Accident &
Health or
Sickness
P – Pr
operty C – Casualty PL – Personal Lines
Limited Lines:
Credit– Credit CR – Car Rental CROP - Crop T – Travel S – Surety O – Other: Specify
Type
License Type Major Lines of Authority Limited Lines of Authority
Jurisdiction
A B P SLP V L H P C PL Credit CR CROP T S O ___________
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VI
VA
VT
WA
WI
WV
WY
37
Check the box and
specify license type:
Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please
reference the National Insurance Producer Registry web site at www.nipr.com
© 2014 National Association of Insurance Commissioners
Page 3 of 5
Uniform Application for
Individual Insurance Producer License/Registration
Applicant Name: _________________________________________________
Back
g
round
Q
uestions
The Applicant must read the following very carefully and answer every question. All written statements submitted by the Applicant must
include an original signature.
1 a. Have you ever been convicted of a misdemeanor, had a judgment withheld or deferred, or are you currently charged with committing a
misdemeanor?
Yes ___ No___
You may exclude the following misdemeanor convictions or pending misdemeanor charges: traffic citations, driving under the influence
(DUI), driving while intoxicated (DWI), driving without a license, reckless driving, or driving with a suspended or revoked license.
You may also exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court)
1b.
Have you ever been convicted of a felony, had a judgment withheld or deferred, or are you currently charged with committing a felony?
You may exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court)
If you have a felony conviction involving dishonesty or breach of trust, have you applied for written consent to engage in the business of
insurance in your home state as required by 18 USC 1033?
If so, was consent granted? (Attach copy of 1033 consent approved by home state.)
Yes __ No ___
N/A___ Yes___ No____
N/A___ Yes___ No____
1c. Have you ever been convicted of a military offense, had a judgment withheld or deferred, or are you currently charged with committing a
military offense?
NOTE: For Questions 1a, 1b and 1c, “Convicted” includes, but is not limited to, having been found guilty by verdict of a judge or jury,
having entered a plea of guilty or nolo contendere or no contest, or having been given probation, a suspended sentence, or a fine.
If you answer yes to any of these questions, you must attach to this application:
a) a written statement explaining the circumstances of each incident,
b) a copy of the charging document,
c) a copy of the official document, which demonstrates the resolution of the charges or any final judgment.
Yes __ No ___
2.
Have you ever been named or involved as a party in an administrative proceeding, including FINRA sanction or arbitration proceeding
regarding any professional or occupational license or registration?
Yes ___ No___
“Involved” means having a license censured, suspended, revoked, canceled, terminated; or, being assessed a fine, a cease and desist order, a
prohibition order, a compliance order, placed on probation, sanctioned or surrendering a license to resolve an administrative action.
“Involved” also means being named as a party to an administrative or arbitration proceeding, which is related to a professional or
occupational license, or registration. “Involved” also means having a license, or registration application denied or the act of withdrawing an
application to avoid a denial. INCLUDE any business so named because of your actions in your capacity as an owner, partner, officer or
director, or member or manager of a Limited Liability Company. You may EXCLUDE terminations due solely to noncompliance with
continuing education requirements or failure to pay a renewal fee.
If you answer yes, you must attach to this application:
a) a written statement identifying the type of license and explaining the circumstances of each incident,
b) a copy of the Notice of Hearing or other document that states the charges and allegations, and
c) a copy of the official document, which demonstrates the resolution of the charges or any final judgment.
3. Has any demand been made or judgment rendered against you or any business in which you are or were an owner, partner, officer or
director, or member or manager of a limited liability company, for overdue monies by an insurer, insured or producer, or have you ever
been subject to a bankruptcy proceeding? Do not include personal bankruptcies, unless they involve funds held on behalf of others.
Yes ___ No___
If you answer yes, submit a statement summarizing the details of the indebtedness and arrangements for repayment, and/or type and
location of bankruptcy.
4. Have you been notified by any jurisdiction to which you are applying of any delinquent tax obligation that is not the subject
of a repayment agreement?
Yes ___ No___
If you answer yes, identify the jurisdiction(s): _______________________________________
5. Are you currently a party to, or have you ever been found liable in, any lawsuit, arbitrations or mediation proceeding involving allegations
of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty?
Yes ___ No___
38
Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please
reference the National Insurance Producer Registry web site at www.nipr.com.
© 2014 National Association of Insurance Commissioners
Page 4 of 5
Uniform Application for
Individual Insurance Producer License/Registration
Applicant Name:
_________________________________________________
If you answer yes, you must attach to this application:
a) a written statement summarizing the details of each incident,
b) a copy of the Petition, Complaint or other document that commenced the lawsuit or arbitration, or mediation proceedings, and
c) a copy of the official documents, which demonstrates the resolution of the charges or any final judgment.
6. Have you or any business in which you are or were an owner, partner, officer or director, or member or manager of a limited liability
company, ever had an insurance agency contract or any other business relationship with an insurance company terminated for any
alleged misconduct?
If you answer yes, you must attach to this application:
a) a written statement summarizing the details of each incident and explaining why you feel this incident should not prevent you
from receiving an insurance license, and
b) copies of all relevant documents.
7. Do you have a child support obligation in arrearage?
If you answer yes,
a) by how many months are you in arrearage?
b) are you currently subject to and in compliance with any repayment agreement?
c) are you the subject of a child support related subpoena/warrant?
(If you answered yes, provide documentation showing proof of current payments or an approved repayment plan from the appropriate
state child support agency.)
8. In response to a “yes” answer to one or more of the Background Questions for this application, are you submitting document(s) to the
NAIC/NIPR Attachments Warehouse?
If you answer yes
Will you be associating (linking) previously filed documents from the NAIC/NIPR Attachments Warehouse to this application?
Note: If you have previously submitted documents to the Attachments Warehouse that are intended to be filed with this application,
you must go to the Attachments Warehouse and associate (link) the supporting document(s) to this application based upon the
particular background question number you have answered yes to on this application. You will receive information in a follow-up
page at the end of the application process, providing a link to the Attachment Warehouse instructions.
Yes ___ No___
Yes ___ No___
________Months
Yes ___ No___
Yes ___ No___
N/A ___ Yes ___ No___
Yes ___ No___
Question 38-5 continued...
Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please
reference the National Insurance Producer Registry web site at www.nipr.com.
© 2014 National Association of Insurance Commissioners
Page 5 of 5
Uniform Application for
Individual Insurance Producer License/Registration
Applicant’s Certification and Attestation
The Applicant must read the following very carefully:
1. I hereby certify that, under penalty of perjury, all of the information submitted in this application and attachments is true and complete. I am aware that
submitting false information or omitting pertinent or material information in connection with this application is grounds for license revocation or denial of
the license and may subject me to civil or criminal penalties.
2. Unless provided otherwise by law or regulation of the jurisdiction , I hereby designate the Commissioner, Director or Superintendent of Insurance, or other
appropriate party in each jurisdiction for which this application is made to be my agent for service of process regarding all insurance matters in the
respective jurisdiction and agree that service upon the Commissioner, Director or Superintendent of Insurance, or other appropriate party of that jurisdiction
is of the same legal force and validity as personal service upon myself.
3. I further certify that I grant permission to the Commissioner, Director or Superintendent of Insurance, or other appropriate party in each jurisdiction for
which this application is made to verify information with any federal, state or local government agency, current or former employer, or insurance company.
4. I further certify that, under penalty of perjury, a) I have no child-support obligation, b) I have a child-support obligation and I am currently in compliance
with that obligation, or c) I have identified my child support obligation arrearage on this application.
5.
I authorize the jurisdictions to which this application is made to give any information concerning me, as permitted by law, to any federal, state or municipal
agency, or any other organization and I release the jurisdictions and any person acting on their behalf from any and all liability of whatever nature by reason
of furnishing such information.
6.
I acknowledge that I understand and will comply with the insurance laws and regulations of the jurisdictions to which I am applying for licensure.
7.
For Non-Resident License Applications, I certify that I am licensed and in good standing in my home state/resident state for the lines of authority requested
from the non-resident state.
8. I hereby certify that upon request, I will furnish the jurisdiction(s) to which I am applying, certified copies of any documents attached to this application or
requested by the jurisdiction(s).
__________________________________________________
Month/Day/Year
_________________________________________________________________
Original Applicant Signature
_________________________________________________________
Full Legal Name (Printed or Typed)
Attachments
The following attachments must accompany the application otherwise the application may be returned unprocessed or considered deficient.
1. For Non-Resident License Applications and unless otherwise noted in the State Matrix of Business Rules, a state will rely on an electronic verification of an
Applicant’s resident license through the NAIC’s State Producer Licensing Database in lieu of requiring an original Letter of Certification from the resident state.
2. Any jurisdiction specific attachments listed in the State Matrix of Business Rules (www.nipr.com).
39
40
Applicant Name:
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space provided above after printing your application.
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NAIC Uniform Application for Individual Producer LicenseRegistration (Arizona)

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Completed 12 August 2020

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