License Document Request Form (Insurance Licensing Section) printable pdf download

License Document Request Form (Insurance Licensing Section)

INSURANCE LICENSING SECTION

2910 N. 44

ST, SUITE 210 • PHOENIX, AZ 85018-7256 •PHONE: 602-912-8470 • FAX: 602-912-8473

LICENSE DOCUMENT REQUEST

Letter of Certification of License Status Request

Enter the FULL name of the licensee (space provided for individual or firm)

Last Name

First Name

Full Name of the Business Entity (If the licensee is a Firm)

AZ Insurance License #

Please enter quantity of Letter(s) of Certification Requested: __________

Fee per Letter of Certification:

$3.00

Total Due:

__________

NOTE: If you wish to have the Letter(s) of Certification mailed, you must include a self-addressed,

stamped envelope. IF you wish to pick up the certification letter(s), please provide a telephone # and

a contact person whom we can contact when ready for pick up

______________________________________

(

)____________________

Contact person’s Name (Please print)

Contact person’s phone #

Request for Replacement License Certificate

Please provide Reason for request for Replacement License Certificate

Name Change –

You must provide your original License Certificate and official documents

evidencing the name change.

Address Change –

You must provide your original License Certificate and your new mailing,

business and or residence address with this request.

Lost or Stolen License Certificate –

You must include a $3.00 fee for a replacement

License Certificate, and provide a statement describing the circumstances of the loss or theft of

your original License Certificate.

__________________________________________________________________________

Form L-198 (v 04/03)

License Document Request Form (Insurance Licensing Section)