Form E-Affcoanew - Certificate Of Authority Application Affidavit
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1Department of Insurance
State of Arizona
Financial Affairs Division
2910 NORTH 44TH STREET, SUITE 210
Phoenix, Arizona 85018-7256
Telephone: (602) 912-8420
Telecopier: (602) 912-8421
CERTIFICATE OF AUTHORITY APPLICATION AFFIDAVIT
State of __________________________
County of _________________________
The undersigned President and Secretary of _______________________________________________,
as “Applicant” for an Arizona Certificate of Authority, do herein attest and avow under penalty of perjury
that the following statements are true:
•
The application is presented solely for the purposes outlined in the Plan of Operation.
•
During the Application review, the Applicant agrees to notify the Arizona Department of Insurance
within five (5) business days of the following:
•
Changes to the Plan of Operation that affects investment, underwriting, marketing or reinsurance
operations.
•
Events which would require a Form D filing (regardless of whether Applicant is subject to
insurance holding company system registration).
•
Events which could lead to a change in control, as defined in A.R.S. § 20-481, of the Applicant.
•
During the Application review process, and upon receipt of a Certificate of Authority, the Applicant
agrees to notify the Arizona Department of Insurance of all proposed changes to its Plan of Operation
at least thirty (30) days prior to implementation of the change.
•
The Applicant acknowledges that failure to adhere to its filed Plan of Operation may be cause for
suspension of an issued and active Arizona Certificate of Authority.
•
Redomestication to the State of Arizona is not under consideration and the Applicant acknowledges
that additional requirements, including financial and market conduct examinations to be performed by
Arizona insurance examiners, would be necessary to redomesticate to the State of Arizona.
•
The Applicant will remit any premium taxes due to the Arizona Department of Insurance for premiums
paid by Arizona residents for policies that were lawfully issued outside of the State of Arizona or
assumed from an insurer authorized to transact insurance in the State of Arizona for any calendar
year(s) preceding its application filing. If applicable, an accounting of Arizona premium income will be
provided in its application for review and computation of taxes due by the Arizona Department of
Insurance.
Signed: ___________________________________
Dated: ___________________
Signed: ___________________________________
Dated: ___________________
NOTARY PUBLIC
On this date, ______________________________, President and _____________________________,
Secretary
of
___________________________________________________________
personally
appeared before me to execute this instrument to avow that the statements contained herein are true and
correct to the best of their knowledge and belief.
Subscribed and sworn to before me this _____ day of ___________________, _________ .
Signature of Notary: __________________________________
My Commission Expires: ______________________________
(Affix Notary Stamp or Seal)
Form E-AFFCOANEW (06/00)
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