Form Scpappl001 - Service Company Permit Application Form - Department Of Insurance, State Of Arizona

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Department of Insurance
State of Arizona
03/05/14
Property and Casualty Division
Telephone: (602) 364-3453
2910 North 44th Street, Suite 210
Phoenix, Arizona 85018-7269
APPLICATION FOR SERVICE COMPANY PERMIT
Please print or type responses
Applicant Name: __________________________________________________________________
Federal tax ID number: _____________________________________________________________
Section A - General
1. Applicant’s Complete Name _______________________________________________________
“d/b/a”, if any ____________________________________________________________________
If a “d/b/a” or other name is used in Arizona, attached a copy of approval of such by the Office of the
Arizona Secretary of State. For assistance, see the website at
Home Office Address: ______________________________________________________________
Arizona Address, if any: ____________________________________________________________
Mailing Address, if different from Home Office Address: ____________________________________
2. Designated contact person name: ___________________________________________________
Telephone number (___) ____________________ Fax number (___) ________________________
Toll free telephone number (___) ________________; E-mail address:________________________
3. The applicant is domiciled in what State: _____________________________________________
4. Applicant is an (check one): ___Association; ___Sole Proprietorship; ___Partnership;
___Corporation; ___Other. If “other”, identify the type of organization ________________________.
5. If the applicant is a corporation or a limited liability company (L.L.C.) and domiciled in a state other
than Arizona, attach a “Certificate of Good Standing” as issued by the Arizona Corporation
Commission. For assistance from the Arizona Corporation Commission, see their website at
.
6. The type of equipment to be serviced by the applicant is (check the appropriate blocks):
___ Motor Vehicles
___ Air conditioning
___ Electronic Equipment
___ Residential Home
___ Heating
___ Other (Specify)
___ Appliances
___ Plumbing
____________________
Section B – Organizational Information
1. Name and address of all predecessor or affiliated firms selling service contracts during the
preceding 10 years (attach a list if additional space is needed). ______________________________
________________________________________________________________________________
2. Name, address and relationship of all firms affiliated with, owned, controlled or controlling the
applicant (attach a list if additional space is needed). ______________________________________
________________________________________________________________________________
SCAPPL001 (Rev. 3/14)
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