Form L-196 - Bond Of Surplus Lines Broker - Insurance Licensing Section printable pdf download

INSURANCE LICENSING SECTION

2910 NORTH 44TH STREET, SUITE 210

PHOENIX, ARIZONA 85018-7256

BOND NO.__________________________

BOND OF SURPLUS LINES BROKER

The licensing of a Surplus Lines Broker by the Director of Insurance is authorized and permitted by Arizona

Revised Statutes (A.R.S.) subject to limitations and conditions therein stated, including the prior filing with the

Director of Insurance of a bond in favor of the State of Arizona in the sum of twenty-five thousand dollars

($25,000) with an authorized corporate surety. This bond is submitted to meet the aforementioned requirements

and is conditioned on the following:

That the Principal will conduct business under the Principal's Arizona surplus line broker license according

to A.R.S., Title 20, Chapter 2, Article 5;

II)

That the Principal, herein named, shall, on or before the first day of March and (commencing 1998) the first

day of September of each year, file with the Director of Insurance a verified statement of all surplus lines insurance

transacted by Principal during the period to which the statement pertains, in accordance with A.R.S. § 20-415, and

shall remit to the State Treasurer, through the Director of Insurance, a three percent (3%) premium tax computed

in accordance with A.R.S. § 20-416;

III)

That the Principal properly account to the person entitled for all monies received by the Principal through

transactions under the Principal's Surplus Lines Broker license;

Whereas, ___________________________________________, as Principal herein, being a duly licensed

insurance agent or broker has heretofore applied to the Director of Insurance for a license as a Surplus Lines

Broker pursuant to said Article 5.

NOW THEREFORE, we

____________________________________________________________________________, as Principal,

and________________________________________________________________________________________

____________, a corporate surety authorized to transact insurance business in the State of Arizona, as surety, do

hereby bind ourselves, our heirs, executors, administrators and successors, jointly and severally to pay to the

State of Arizona the sum of twenty-five thousand dollars ($25,000) lawful money of the United States in the event

that the aforesaid Principal fails to comply with any or all conditions of this bond.

This bond, drawn and executed in the manner prescribed by A.R.S. § 20-411(D), shall remain in force until

released by the Director of Insurance or until terminated by the Surety. In accordance with A.R.S. § 20-411(E)

without prejudice to any liability previously incurred thereunder, the Surety may terminate this bond upon thirty (30)

days advance written notice filed with the Director of Insurance.

IN WITNESS WHEREOF, we have hereunto set our hands and affixed our seals this______day

of________________, 19____.

_______________________________________________

(Signature of Principal)

Countersigned at:

_______________________________________________

(Print Name of Surety)

___________________________ (City, State)

_______________________________________________

(Signature of Attorney-in-Fact)

_________________________________________

Signature of Agent (Other Than Principal)

(Surety's Power of Attorney Must Be Attached to this Bond)

(Affix Surety's Seal)

Form L-196 Ed.

02/99

Form L-196 - Bond Of Surplus Lines Broker - Insurance Licensing Section

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