Form Scpappl001 - Service Company Permit Application Form - Department Of Insurance, State Of Arizona Page 3

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4. Include a copy of the applicant’s service contract(s), to include all applications, service contract
forms, brochures and any other forms used in the sale of service contracts.
5. Motor vehicle dealers using an approved program of a licensed service company must provide a
motor vehicle dealer’s notice of intent form.
Attachments:
Bond of Service Company – Form SC002
Arizona Biographical Affidavit – Form E110.RAR
Trust Deposit Packet – Form E003
Notice of Service Company Deposit Delivery – Form E125
Notice of Service Company Deposit Release – Form E126
Motor Vehicle Dealer’s Notice of Intent
Contact Erica Bowsher: (602) 364-3453, fax (602) 364-3989 or e-mail
ebowsher@azinsurance.gov
regarding Service Company Permit questions.
Section F – Verification of Affidavit
State of: _________________
County of: ________________
I, __________________________, being duly sworn, depose and say that I am an officer of
__________________________________________________________
Complete name of the applicant
that I am duly authorized to bind the applicant, and that all information provided in all
sections of this application and in all attachments thereto are true and correct to the
best of my knowledge and belief, and I understand that any misrepresentation or
omission of a material fact in this application or the attachments hereto is grounds
for denial or revocation of the permit.
___________________________________________
Printed Name of Authorized Representative
___________________________________________
___________________________
Signature
Date of Signature
_______________________________________
Title
SUBSCRIBED AND SWORN TO Before me this ______Day of _____________ _____
By __________________________________
______________________
________________________
Signature of Notary
My Commission Expires
Public
SCPAPPL001 (Rev. 3/14)
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