Form L-107 - Affidavit Of Managing General Agent
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1
2INSURANCE LICENSING SECTION
2910 NORTH 44TH STREET, SECOND FLOOR
FORM L-107
PHOENIX, ARIZONA 85018-7256
AFFIDAVIT OF MANAGING GENERAL AGENT
THIS DOCUMENT MUST BE COMPLETED BY AN OFFICER OF THE INSURANCE
COMPANY (the "insurer" named in Section A below). The completed affidavit must be
included with the license application of the prospective managing general agent.
SECTION A
Full name of the INSURER that the MGA named in Section B will represent:
NAIC Number:
Insurer
Street address of insurer:
Information
SECTION B
Full name of the MGA that will represent the insurer named in Section A:
MGA Information
Street address of MGA:
City
State:
Zip Code:
SECTION C
Does or will the MGA named in Section B:
1. EITHER
Scope of MGA
Responsibilities
a. Negotiate and bind ceding reinsurance
contracts on behalf of the insurer in Section
A? OR
b. Manage all or part of the insurance business of
the insurer, including the management of a
separate division, department or underwriting
¨
¨
office?
Yes
No
2. AND act as an insurance producer or agent for the
¨
¨
insurer?
Yes
No
3. AND produce and underwrite, with or without
authority and either separately or together with
affiliates, directly or indirectly, an amount of gross
direct written premium that is equal to or exceeds
5% of the policyholder surplus as reported in the
last annual statement of the insurer in any one
¨
¨
quarter or year?
Yes
No
4. AND EITHER
a. engage in the adjustment or payments of
claims OR
b. negotiate reinsurance on behalf of the
¨
¨
insurer?
Yes
No
CONTINUED ON THE REVERSE
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