Service Company Permit Renewal Form - Department Of Insurance, Arizona
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1
2Department of Insurance
State of Arizona
Property and Casualty Division
Telephone: (602) 364-3453
GERMAINE L. MARKS
DOUGLAS A. DUCEY
2910 North 44th Street, Suite 210
Phoenix, Arizona 85018-7269
Governor
Director of Insurance
https://azinsurance.gov
SERVICE COMPANY PERMIT RENEWAL
APPLICATION, AFFIDAVIT AND CERTIFICATION
This application affidavit must be executed by the owner, general partner, chief executive officer or
chief operating officer having full authority to execute this affidavit on the Service Company’s behalf.
Service Company’s complete legal name:
State of domicile: __________________________.
“DBA”, or “other name” to be used in this State as approved by the Arizona Secretary of State (if
any): _____________________________________________________.
I, ________________________________________, (insert name and title of affiant - see above)
being first duly sworn, do hereby certify the following:
1. The most recent financial statement (balance sheet & income statement) attached and made part
hereof, is a true and correct statement of the financial condition and affairs of the Service
Company named above as of the date stated in the statement. (see Arizona Administrative Code
R20-6-407.C.2.a).
2. The Service Company has not failed to pay within sixty (60) days any judgement in favor or a
service contract holder or his heir or assignee (attach a complete description of any exceptions).
3. The Service Company, its agents, officials and representatives have not violated any provisions of
Arizona Revised Statutes, §§ 20-1095 through 20-1095.10 (attach a complete description of any
exceptions).
4. No changes have been made in:
a. The information provided in the original permit application;
b. The filed “Service Company Permit” bond or alternatives to cash provided pursuant to A.R.S
§20-1095.04, and;
c. The service contract program(s) offered, except as fully described by attachment hereto
(complete the attached List of Forms Exhibit).
5. The alternative to cash filed with the Director has a current market value of at least $100,000 (see
A.R.S. § 20-1095.04).
6. All Service Contract(s), sold by the company in this State, are in compliance with Arizona
Administrative Code R20-6-407(E) and have been approved by this Department.
SCRenewalAppl rev. 3/14
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