Form Dl-9106 - Insurance Company/agency Affidavit Of Intended Use Page 2

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INSTRUCTIONS FOR COMPLETING THE AFFIDAVIT OF INTENDED USE
1. The affidavit must be completed and signed by a member of your agency or firm who has the
authority to certify the agency or firm’s compliance.
2. Please complete each line on the form in its entirety to avoid delays in processing your affidavit.
If requested information does not apply to your business insert n/a (not-applicable) on that line.
3. List all state Licensing Information on the affidavit that allows you to engage in the insurance
business, and attach a copy of your insurance certificate(s) and/or license(s).
4. The person responsible for completing the affidavit must initial each of the eight (8) declaration
statements, then sign and date the form in the presence of a Notary.
5. This affidavit must be returned to your information provider.
6. You are required to complete, notarize and file a new Affidavit of Intended Use whenever information
about your company changes. (name, address, ownership, telephone, website, etc.)
7. If you need assistance in completing this affidavit, please contact your information provider.

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