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SECTION V: ADDITIONAL INFORMATION

Carefully read the questions below and check either "YES" or "NO." For the purposes of this application, “convicted” includes, but is not limited to, having been found

guilty by judge or jury or pled guilty or no contest to any felony, misdemeanor or open-ended offense. A “NO” response is incorrect if applicant has had any conviction

dismissed, expunged, pardoned, appealed, set aside or reversed, or if licensee had its civil rights restored, had a plea withdrawn or if applicant has been given probation,

a suspended sentence, was issued a fine, successfully completed a diversion program, etc. If “YES” is answered to any of the following, carefully read the instructions

to Section VI, “COMPLETING THE APPLICATION,” for additional information.

A. Has the applicant or any individual designated in the application as a principal or any individual who is to

Yes

exercise the powers conferred by the license been convicted of a felony?

Has the applicant or any individual designated in the application as a principal or any individual who is to

Yes

exercise the powers conferred by the license had any professional license, vocational license, business license or

certification refused, denied, suspended, revoked or restricted?

C. Has the applicant or any individual designated in the application as a principal or any individual who is to

Yes

exercise the powers conferred by the license withdrawn any application or surrendered any license to avoid any

disciplinary action or the denial of a license?

D. Has the applicant or any individual designated in the application as a principal or any individual who is to

exercise the powers conferred by the license had any judgment, order or other determination issued or imposed

in any criminal, civil, administrative or other judicial or quasi-judicial proceeding of any kind in any jurisdiction

based on any of the following:

1. Misappropriation, conversion or the withholding of moneys?

Yes

2. Incompetence or a source of injury and/or loss to anyone?

Yes

3. Dishonesty in business or financial matters?

Yes

4. Fraud or misrepresentation?

Yes

5. Any cause arising out of an insurance transaction?

Yes

Are any civil, administrative, other judicial or quasi-judicial proceedings of any kind, or any criminal proceedings

in which an indictment, criminal complaint or information has been issued naming the applicant or any individual

designated in the application as a principal or individual who is to exercise the powers conferred by the license,

as defendant, currently pending in any jurisdiction based on any of the following:

1. Misappropriation, conversion or the withholding of moneys?

Yes

2. Incompetence or a source of injury and/or loss to anyone?

Yes

3. Dishonesty in business or financial matters?

Yes

4. Fraud or misrepresentation?

Yes

5. Any cause arising out of an insurance transaction?

Yes

F. Has the applicant or any individual designated in the application as a principal or any individual who is to

Yes

exercise the powers conferred by the license had an agency contract terminated by an insurance company or

managing general agent for any alleged cause?

G. Is the applicant or any individual designated in the application as a principal or any individual who is to exercise

Yes

the powers conferred by the license presently indebted to any insurer or any insurance company or managing

general agent?

AFFIDAVIT OF VERIFICATION (must be executed by two members, officers, directors, trustees or, if a limited liability company, managers)

STATE OF:

)

) ss.

COUNTY OF:

)

____________________________________________ and ______________________________________, being first duly sworn, depose and say: We are the

authorized individuals who represent the applicant named hereon which is organized under the laws of the State of Arizona or possesses official authority to do business

in Arizona. We have read the application and accompanying materials, and each statement, answer, attachment and enclosure provided in the application and

accompanying materials are true, complete and correct. We acknowledge that if there exists any fraud or misrepresentation in attempting to obtain any insurance license

in this State, the Director of Insurance may refuse to accept any application for a license. We agree to promptly notify the director of all changes to members, directors

and officers in accordance with A.R.S. § 20-411(F)(4).

SUBSCRIBED AND SWORN TO before me this ______ day of _________________________, _________.

________________________________________

__________________________________________________________________________

Notary Public

Print or Type Applicant’s Full Name

By:

______________________________________

__________________________________

My commission expires: _____________

Signature of Authorized Representative

Official Title