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Original / Amended
Financial Affairs Division
Arizona Department of Insurance
100 North 15th Avenue, Suite 102
Phoenix, AZ 85007-2624
LIFE SETTLEMENT PROVIDER
APPLICATION FOR CERTIFICATE OF AUTHORITY
Applicant Name
Alternate (Assumed) Name / DBA
Federal Employer Identification
Number (FEIN)
HOME OFFICE Street Address City State ZIP Code
MAILING Address City State ZIP Code
Toll-free Phone Main Phone FAX Number
Type of Entity (select only one)
Stock Corporation Individual Partnership
Limited Liability Company Other (Describe): ____________________________________________
Date Incorporated/Formed State Where Incorporated/Formed Fiscal Year Ends on
December 31
Other (mm/dd) : _____/_____
Name E-mail Address
Street Address City State ZIP Code
CONTACT
PERSON
Toll-free Phone Main Phone FAX Number
Note: Within Arizona, a life settlement provider must only use life settlement contracts and disclosure statements that have been
approved by the Department of Insurance Life and Health Division. See the Department of Insurance “Life Settlements” web page
(http://www.azinsurance.gov/lifesettlements
) for details.
ATTESTATION AND CERTIFICATION
(Must be signed by an officer, director, member or partner of the applicant)
By signing this form, the signatory attests and certifies to all the following:
All information contained in the application and any attachments, enclosures and supplements thereto, are true, complete and
accurate, to the best of the signatory’s knowledge and belief.
The applicant, and each of the applicant’s officers, directors, members, partners and designated employees who shall have
authority to act under a resultant certificate of authority issued to the applicant understand they must comply with ARS §§ 20-3201
et seq. and other Arizona laws pertinent to acting as a life settlement provider including but not limited to the following provisions:
Privacy requirements set forth in ARS §§ 20-3205, 20-3211(H), 20-2101 et seq. and applicable federal laws;
Annual statement requirements set forth in ARS § 20-3210;
Requirements for viatical or life settlement contracts set forth in ARS § 44-1841 et seq. (esp. ARS § 44-1850);
Requirements to only use licensed life settlement brokers to perform life settlement broker activities. ARS § 20-3202(I).
___________________________
Date
_______________________________________________________
Signature
_______________________________________________________
PrintedName
Form E-LSP1 (v. 20180716)
_________________________________________
Title
