Fillable form to apply for a license online. NIPR (Arizona)

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Page 1 of 5 AZDOI Form L-176 Instructions (v. 20190712)
ADOI
FORM L-176
INSTRUCTIONS
NAIC Uniform Application for
Business Entity License/Registration
LICENSING
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 FORM L-176…
• To renew a license. Use www.nipr.com to renew your license.
• To obtain a license for a sole proprietorship. Individuals must use NIPR or Form L-169 to apply for
an insurance license and Form L-193 to apply to use an assumed name.
• To apply for a life settlement broker license. Use NIPR or Form L-LSB instead.
• To apply for a rental car, self-service storage, travel insurance producer or portable
electronics vendor license. Use NIPR or Form L-LTD instead.
• To apply for a license as a health insurance exchange navigator or certified application
counselor. Use NIPR or 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.
If completing Form L-176 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.
If submitting paper Form L-176: Clearly print in ink or type all information.
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.
FORM L-176 INSTRUCTIONS
Page 2 of 5 AZDOI Form L-176 Instructions (v. 20190712)
1. OFFICE LOCATIONS: If the applicant transacts business at any additional OFFICE location other than the
address provided in Section I, submit Form L-LOC with the application.
2. 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 Producer License ............................
(one or more lines of authority)
$120.00
Title Insurance Agent ........................................
$120.00
Insurance Adjuster License .............................
• insurance adjuster or
• portable electronics insurance adjuster
$120.00
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.
Bail Bond Agent License ..................................
Fingerprint Card Processing Fee .....................
$120.00 plus
$22.00 for each owner and shareholder of the
bail bond agent
.
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)]
3. LICENSE TERM:
• A license issued to a previously unlicensed business entity expires on the last day of the month, four
years after the date of issuance.
• License authority issued to a business entity that already holds an Arizona insurance license expires as
follows:
For insurance producer or surplus lines broker, the same date as existing insurance producer or
surplus lines authority, regardless of the term remaining on the license.
For adjuster or bail bond agent licenses, the last day of the month, four years after the date of
issuance.
4. If you answer “YES” to one or more of the questions in Section V, 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
FORM L-176 INSTRUCTIONS
Page 3 of 5 AZDOI Form L-176 Instructions (v. 20190712)
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.
5. 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 prohibits any person convicted of
any criminal felony involving dishonesty, breach of trust or a violation of the Act from engaging in the
business of insurance without the specific written consent of the appropriate state insurance regulatory
official. 18 U.S.C. § 1033. A person who does not obtain the specific written consent may be subject
to federal criminal prosecution
possess a license. Further, the Act 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 criminal sanctions.
A license issued by the Arizona Department of Insurance DOES NOT satisfy other business
licensing requirements
insurance license in order to lawfully operate its business in Arizona.
• ARIZONA CORPORATION COMMISSION: www.azcc.gov | 602-542-3026
6. IF YOU ARE APPLYING FOR A NONRESIDENT LICENSE:
• You must hold an active resident license in your home state (a US state or territory)
UNLESS BOTH OF
THE FOLLOWING ARE TRUE
:
you are applying to become a nonresident Portable Electronics Adjuster,
AND
you reside in a state that does not license adjusters.
• Your resident state license will be electronically verified and must be in good standing.
7. IF YOU ARE APPLYING FOR AN ARIZONA RESIDENT LICENSE:
• Principal Place of Business:
To apply as an Arizona resident, documents that the business submitted to a government agency to
create/form the business must show an Arizona address as the business entity’s principal place of
business. A.R.S. § 20-281(4)(b)
• Organizational documents:
Include with your license application the following based on the applicant’s entity type:
If the applicant is a corporation or limited liability company, submit a copy of the
ARTICLES OF
INCORPORATION or ARTICLES OF ORGANIZATION stamped as “filed” with the Arizona Corporation
Commission. The articles must show that the primary business address is within Arizona.
If the applicant is a partnership, submit with the application a copy of the written
PARTNERSHIP
AGREEMENT and CERTIFICATE OF REGISTRATION stamped as “recorded” in the office of the Arizona
Secretary of State, or if organized outside Arizona, stamped “recorded” by the government office
where the partnership was recorded. The partnership agreement must show the primary business
address as being within Arizona.
FORM L-176 INSTRUCTIONS
Page 4 of 5 AZDOI Form L-176 Instructions (v. 20190712)
If the applicant is a business trust, include a copy of the filed and recorded trust agreement.
If the business was organized in a state that requires the entity to record its principal business address
as being outside Arizona, the business entity can apply for a nonresident insurance license but cannot
apply for an Arizona resident insurance license.
8. IF YOU ARE APPLYING FOR A BAIL BOND AGENT LICENSE:
• 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.
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).
• Fingerprints:
Each owner and stockholder (member, officer, director, etc.) must be individually licensed in Arizona as
a bail bond agent [A.R.S. § 20-341.01(B)] and the applicant must include a completed fingerprint card
for each in accordance with the following:
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.
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.
FORM L-176 INSTRUCTIONS
Page 5 of 5 AZDOI Form L-176 Instructions (v. 20190712)
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
contact 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.
9. 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, each individual
and each business entity must possess a surplus lines broker license issued by the Arizona
Department of Insurance. A.R.S. § 20-411(A).
• If the individual and business entity will only be selling, soliciting or negotiating alien insurance for
coverage in Mexico (pursuant to A.R.S. § 20-422), the individual and business entity may apply for a
Mexican Insurance Surplus Lines Broker license instead of a Surplus Lines Broker license.
10. IF YOU ARE APPLYING FOR A TITLE AGENT LICENSE:
• Submit a letter of authorization from the Arizona-admitted title insurance company that the applicant
will represent subject to being issued a license.
• Title agent names must comply with standards established in A.R.S. § 20-1583(A).
• A title agent may only be a domestic or foreign stock corporation or LLC.
11. 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 (https://insurance.az.gov/producers
).
IMPORTANT: If Section III identifies another business entity as a principal of the applicant, Section III
must include information about the other business entity’s principals; responses in Section V must reflect
those principals.
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 7
Uniform Application for
Business Entity License/Registration
(Please Print or Type)
Check appropriate boxes for license requested.
Resident License
Non-Resident License
Identify Home State: _______________
Identify Home State License No.: _____________
New Application
Demographic Information
Business Entity Name Incorporation/Formation Date
(month) ___ (day) ___ (year) ___
FEIN
If assigned, National Producer Number (NPN) If applicable, FINRA Firm Central Registration Depository (CRD)
List any other assumed, fictitious, alias or trade names under which you are currently
doing business or intend to do business.
State of Domicile Country of Domicile
Is the business entity affiliated with a financial institution/bank? Yes No
Business Address City State ZIP Code Foreign Country
Phone Number (include Ext.)
(
)
Fax Number
(
)
Business Web Site Address Business E-Mail Address
Mailing Address P.O. Box City State ZIP Code Foreign Country
Designated/Responsible Licensed Producer
Identify at least one Designated/Responsible Licensed Producer responsible for the business entity’s compliance with the insurance laws, rules and regulations of this
state. (See Matrix of State Requirements at www.nipr.com for jurisdictions that require the designated/responsible licensed producer to be an officer, director or partner
of the business entity.)
Name SSN NPN
Name SSN NPN
Name SSN NPN
Name SSN NPN
Owners, Partners, Officers and Directors
Identify all owners with 10% interest or voting interest, partners, officers and directors of the business entity, or members or managers of a limited liability company:
Name
Title SSN/FEIN DOB ___________ Owner:
Yes
No Ownership Interest: %
Name
Title SSN/FEIN DOB ___________ Owner:
Yes
No Ownership Interest: %
Name
Title SSN/FEIN DOB ___________ Owner:
Yes
No Ownership Interest: %
Name
Title SSN/FEIN DOB ___________ Owner:
Yes
No Ownership Interest: %
Name
Title SSN/FEIN DOB ___________ Owner:
Yes
No Ownership Interest: %
1
3
15 16 17
18
26
25
6
7
8
4
5
9
11 12 14 10
2
13
19
20
21
22
23
24
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.
Uniform Application for
Business Entity License/Registration
Applicant Name: ______________________________________________
© 2014 National Association of Insurance Commissioners Page 2 of 7
Additional Line(s) of Authority
(State Use)
Name
Title SSN/FEIN DOB ___________ Owner:
Yes
No Ownership Interest: %
Name
Title SSN/FEIN DOB ___________ Owner:
Yes
No Ownership Interest: %
Name
Title SSN/FEIN DOB ___________ Owner:
Yes
No Ownership Interest: %
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 7
Uniform Application for
Business Entity License/Registration
Applicant Name: ______________________________________________
Jurisdiction and T
yp
e of License/Re
g
istration Re
q
uested — M
AJO
R
Lines of Authorit
y
Next to each jurisdiction, check the legal business type, license/registration type(s) and line(s) of authority for which you are applying.
Legal Business Type:
C – Corporation
P – Partnership
S – Sole Proprietorship
LLC – Limited Liability
Company
LLP – Limited Liability
Partnership
License/Registration
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 – Property
C – Casualty P L – Personal Lines
Jurisdiction Legal Business Type License/Registration Type Lines of Authority
C P S LLC LLP A B P SLP V L H P C PL
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
VA
VI
VT
WA
WI
WV
WY
27
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.
Uniform Application for
Business Entity License/Registration
Applicant Name: ______________________________________________
© 2014 National Association of Insurance Commissioners Page 4 of 7
Jurisdiction and T
yp
e of License/Re
g
istration — L
IMITED
Lines of Authorit
y
Next to each jurisdiction, check the legal business type, license/registration type(s) and line(s) of authority for which you are applying.
Legal Business Type:
C – Corporation
P – Partnership
S – Sole Proprietorship
LLC – Limited Liability
Company
LLP – Limited Liability
Partnership
License/Registration
Types :
A – Agent
B – Broker
P – Producer
SLP – Surplus Lines Producer
Limited Lines: Credit – Credit C
R
– Car Rental CROP – Crop T – Travel S – Surety O – Other: Specify Type
Jurisdiction Legal Business Type License/Registration Type Lines of Authority
C P S LLC LLP A B P SLP 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
VA
VI
VT
WA
WI
WV
WY
28
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.
Uniform Application for
Business Entity License/Registration
Applicant Name: ______________________________________________
© 2014 National Association of Insurance Commissioners Page 5 of 7
Back
g
round
Q
uestions
Please read the following very carefully and answer every question. All written statements submitted by the Applicant must
include an original signature.
1a. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited
liability company, ever been convicted of a misdemeanor, had a judgment withheld or deferred or is the business entity or any
owner, partner, officer or director
of the business entity, or member or manager 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) or 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 juvenile court.)
1b. Has the business entity or any owner, partner, officer or director of the business entity,
or member or manager of a limited
liability company ever been convicted of a felony, had judgment withheld or deferred, or is the business entity or any owner,
partner, officer or director of the business entity or member or manager of a limited liability company 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.) ......................................................................
1c. Has the business entity or any owner, partner, officer or director of the business entity
or member or manager of a limited
liability company, ever been convicted of a military offense, had a judgment withheld or deferred, or is the business entity or
any owner, partner, officer or director of the business entity
or member or manager of a limited liability company, currently
charged with committing a military offense?.....................................................................................................................................
Yes No
N/A Yes No
N/A Yes No
Yes No
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 identifying all parties involved (including their percentage of ownership, if any) and 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.
2. Has the business entity or any owner, partner, officer or director of the business entity, or manager or member of a limited
liability company, ever been named or involved as a party in an administrative proceeding, including a 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 application denied or
the act of withdrawing an application to avoid a denial. 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, all parties involved (including their percentage of ownership, if
any) 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 the business entity or any owner, partner, officer or director of the
business entity, 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.
4. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited
liability company, ever 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):
29
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.
Uniform Application for
Business Entity License/Registration
Applicant Name: ______________________________________________
© 2014 National Association of Insurance Commissioners Page 6 of 7
5. Is the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited
liability company, a party to, or ever been found liable in any lawsuit or arbitration proceeding involving allegations of fraud,
misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty? ..............................................................
Yes No
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 arbitrations, or mediation
proceedings and
c) a copy of the official documents which demonstrates the resolution of the charges or any final judgment.
6. Has the business entity or any owner, partner, officer or director of the business entity, 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.
Yes No
7. 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
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.
Uniform Application for
Business Entity License/Registration
Applicant Name: ______________________________________________
© 2014 National Association of Insurance Commissioners Page 7 of 7
Applicant’s Certification and Attestation
On behalf of the business entity or limited liability company, the undersigned owner, partner, officer or director of the business entity, or member or manager of a
limited liability company, hereby certifies, under penalty of perjury, that:
1. All of the information submitted in this application and attachments is true and complete and I am aware that submitting false information or omitting pertinent or
material information in connection with this application is grounds for license or registration revocation and may subject me and the business entity or limited
liability company to civil or criminal penalties.
2. Unless provided otherwise by law or regulation of the jurisdiction , the business entity or limited liability company hereby designates the Commissioner, Director
or Superintendent of Insurance, or an appropriate representative in each jurisdiction for which this application is made to be its agent for service of process
regarding all insurance matters in the respective jurisdiction and agree that service upon the Commissioner or Director of that jurisdiction is of the same legal
force and validity as personal service upon the business entity.
3. The business entity or limited liability company grants permission to the Commissioner or Director of Insurance in each jurisdiction for which this application is
made to verify any information supplied with any federal, state or local government agency, current or former employer or insurance company.
4. Every owner, partner, officer or director of the business entity, or member or manager of a limited liability company, either a) does not have a current child-
support obligation, or b) has a child-support obligation and is currently in compliance with that obligation.
5.
I authorize the jurisdictions to which this application is made to give any information they may have 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 comply with the insurance laws and regulations of the jurisdictions to which I am applying for licensure/registration.
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).
9. I certify that the Designated Responsible Licensed Producer(s) named on this application understands that he/she is responsible for the business entity’s
compliance with the insurance laws, rules and regulation of the State.
Must be signed by an officer, director, or partner of the business entity,
or member or manager of a limited liability company:
Month/Day/Year
Signature
Typed or Printed Name
Title
Address
City State Zip
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 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).
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form to apply for a license online. NIPR (Arizona)

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Completed 12 August 2020

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