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Page 1 of 2 Form PRR (07/2018)
ARIZONA DEPARTMENT OF INSURANCE
PUBLIC RECORDS REQUEST FORM
insurance.az.gov
For Department Use Only
Request #:
-___-_______
(DIV) (CY) (SEQ #)
Date Received:
____/____/20____
Date Completed:
____/____/20____
Please mail
fax or deliver
this form to:
Attn:
ARIZONA DEPARTMENT OF INSURANCE
100 North 15
th
Avenue, Suite 102
Phoenix, AZ 85007-2624
Your Name: Area Code & Phone: Area Code & Fax:
Your Mailing Address: City: State: ZIP Code:
Your Email Address:
How would you like to receive the records (select only one):
By mail By fax Pick up in person (we will call you when your records are ready for retrieval)
Below, describe the record(s) you wish to inspect, have copied or have provided in a list:
1.
2.
3.
4.
Request is for: Record Inspection (no additional information required on this form) Photocopies*
Certified Copies* List of Records *
* The remainder of this form must be completed
Commercial purpose question: Do you or does anyone for whom you are acting as an agent intend to do any
of the following with the public document(s) you are requesting:
Yes No
1. Use the public record for the purpose of sale or resale or for the purpose of producing a
document containing all or part of the copy, printout or photograph for sale?
2. Use the names and addresses from the public record for the purpose of solicitation?
3. Sell the names and addresses to another for the purpose of solicitation or for any
purpose in which the purchaser can reasonably anticipate the receipt of monetary gain
from the direct or indirect use of the public record?
If you answered “Yes” to any of the preceding questions, your request is for a “COMMERCIAL
PURPOSE.” COMMERCIAL PURPOSE does not include the use of a public record as evidence or as
research for evidence in any action in any judicial or quasi-judicial body. Pursuant to Arizona law, briefly
describe the specific commercial purpose in the space below:
CERTIFICATION: I, __________________________________, the
requesting party, hereby certify that I have
read ARS § 39-121.03 and I understand its contents. I further certify that the information I have provided in this form is
true and correct. I understand that a person who knowingly certifies or files a false or forged instrument is guilty of a
class 6 felony in accordance with ARS § 39-161.
Signature of Requesting Party Date
0
<SELECT ONE OF OUR DIVISIONS>
Page 2 of 2 Form PRR (07/2018)
ARS § 39-121.03. Request for copies, printouts or photographs; statement of purpose; commercial
purpose as abuse of public record; determination by governor; civil penalty; definition
A. When a person requests copies, printouts or photographs of public records for a commercial purpose,
the person shall provide a statement setting forth the commercial purpose for which the copies, printouts
or photographs will be used. Upon being furnished the statement the custodian of such records may
furnish reproductions, the charge for which shall include the following:
1. A portion of the cost to the public body for obtaining the original or copies of the documents,
printouts or photographs.
2. A reasonable fee for the cost of time, materials, equipment and personnel in producing such
reproduction.
3. The value of the reproduction on the commercial market as best determined by the public body.
B. If the custodian of a public record determines that the commercial purpose stated in the statement is a
misuse of public records or is an abuse of the right to receive public records, the custodian may apply to
the governor requesting that the governor by executive order prohibit the furnishing of copies, printouts
or photographs for such commercial purpose. The governor, upon application from a custodian of public
records, shall determine whether the commercial purpose is a misuse or an abuse of the public record. If
the governor determines that the public record shall not be provided for such commercial purpose the
governor shall issue an executive order prohibiting the providing of such public records for such
commercial purpose. If no order is issued within thirty days of the date of application, the custodian of
public records shall provide such copies, printouts or photographs upon being paid the fee determined
pursuant to subsection A.
C. A person who obtains a public record for a commercial purpose without indicating the commercial
purpose or who obtains a public record for a noncommercial purpose and uses or knowingly allows the
use of such public record for a commercial purpose or who obtains a public record for a commercial
purpose and uses or knowingly allows the use of such public record for a different commercial purpose
or who obtains a public record from anyone other than the custodian of such records and uses it for a
commercial purpose shall in addition to other penalties be liable to the state or the political subdivision
from which the public record was obtained for damages in the amount of three times the amount which
would have been charged for the public record had the commercial purpose been stated plus costs and
reasonable attorney fees or shall be liable to the state or the political subdivision for the amount of three
times the actual damages if it can be shown that the public record would not have been provided had the
commercial purpose of actual use been stated at the time of obtaining the records.
D. For the purposes of this section, "commercial purpose" means the use of a public record for the purpose
of sale or resale or for the purpose of producing a document containing all or part of the copy, printout or
photograph for sale or the obtaining of names and addresses from public records for the purpose of
solicitation or the sale of names and addresses to another for the purpose of solicitation or for any
purpose in which the purchaser can reasonably anticipate the receipt of monetary gain from the direct or
indirect use of the public record. Commercial purpose does not mean the use of a public record as
evidence or as research for evidence in an action in any judicial or quasi-judicial body.
Cost of co
p
ies, certifications and lists:
Retrieve and re-file records from record storage center $3.00 per box
Copy of document, non-commercial purpose $0.60 per page
Copy of document, commercial purpose $1.50 per page
Certificate of director under seal $3.00 per document
List of names and addresses, non-commercial purpose $0.03 per record; $15.00 minimum
List of names and addresses, commercial purpose $0.06 per record; $60.00 minimum
List of names, addresses and e-mails, commercial purpose $0.10 per record; $100.00 minimum
Copy of audio tape/CD/DVD (you must provide the blank media) $25.00 ea.
Subpoena (per ARS § 12-351(F)) $25.00/hour plus $0.25 per page.
Mailing costs: Submit a pre-addressed air-bill label containing your billing account number (FedEx/UPS/etc.) in lieu of paying mailing costs.
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Completed 20 July 2020

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