Form L-176/slb - Application For A Surplus Lines Broker License For Firm Or Corporation
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2FORM L-176/SLB
Arizona Department Of Insurance
APPLICATION FOR A SURPLUS LINES BROKER LICENSE FOR FIRM OR CORPORATION
1. CAREFULLY READ THE ENCLOSED INSTRUCTIONS. Your application must be printed or typed.
2. Complete BOTH SIDES of this form and fulfill all other requirements shown in the instructions.
3. Send application and fee payment together with other required materials to the following address:
INSURANCE LICENSING SECTION, 2910 North 44th Street, Suite 210, Phoenix, AZ 85018-7256
SECTION I: BUSINESS INFORMATION
Full Name of Applicant
Physical street address (may not be P.O. box)
City
State
Zip Code
Mailing address to appear on license (if left blank, box B address will appear on license)*
City
State
Zip Code
Telephone Number
* The physical street address may not be a post office box. The mailing address may be a post office box if desired.
NOTE: If the applicant shall transact business at locations other than the physical address identified in Section I,
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)
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applicant must attach a signed and dated list of the other locations and, for each location, listing the name and
Arizona insurance license number of each person who will transact insurance on behalf of the applicant.
SECTION II: LICENSE SELECTION
Write an “X” to the left of the license authority for which you are applying:
q
q
Surplus Lines Broker
Mexican Insurance Surplus Lines Broker
SECTION III: PRINCIPALS OF THE CORPORATION/PARTNERSHIP
List the names and titles of the firm's principals, including all
owners with only a 10% or greater share of voting rights excluding ownership in publicly traded securities, directors, officers, and partners. If additional space is required,
attach a signed and dated list.
Name:
Title:
Name:
Title:
Name:
Title:
Name:
Title:
Name:
Title:
Name:
Title:
SECTION IV: LICENSED REPRESENTATIVES OF APPLICANT
List the FULL names and Arizona insurance license numbers of all
individuals who are to exercise the powers conferred by the license. If additional space is required, attach a signed and dated list.
Name:
AZ License #
Name:
AZ License #
Name:
AZ License #
Name:
AZ License #
Name:
AZ License #
Name:
AZ License #
Name:
AZ License #
SPACE BELOW IS FOR INSURANCE DEPARTMENT USE ONLY
License Type: __________________
License Number: ________________
Issued Date:
_____/_____/______
Expiration Date: _____/_____/______
Exam Passed: _____/_____/______
_____________________________
____________________________
Approved for Licensing by: ________________________________________
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CONTINUED ON THE FOLLOWING PAGE
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L-176/SLB (Eff. 01/2001)
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