Form L-196mex - Bond Of Mexican Insurance Surplus Lines Broker printable pdf download

INSURANCE LICENSING SECTION

2910 NORTH 44TH STREET, SUITE 210

PHOENIX, ARIZONA 85018-7256

BOND NO.________________

BOND OF MEXICAN INSURANCE SURPLUS LINES BROKER

The licensing of a Mexican Insurance Surplus Lines Broker by the Director of Insurance is authorized and

permitted by Arizona Revised Statutes (A.R.S.) subject to limitations and conditions therein stated, including the

prior filing with the Director of Insurance of a bond in favor of the State of Arizona in the sum of one thousand

dollars ($1,000) with an authorized corporate surety. This bond is submitted to meet the aforementioned

requirements and is conditioned on the following:

That the Principal will conduct business under the Principal’s Mexican Insurance Surplus Lines Broker

license according to A.R.S., Title 20, Chapter 2, Article 5 to the extent applicable;

II)

That the Principal properly account to the person entitled for all monies received by the Principal through

transactions under the Principal’s Mexican Insurance Surplus Lines Broker license;

Whereas, ___________________________________________, as Principal herein, being a duly licensed

insurance agent or broker has heretofore applied to the Director of Insurance for a license as a Mexican Insurance

Surplus Lines Broker pursuant to said Article 5.

NOW THEREFORE, we

____________________________________________________________________________, as Principal,

and________________________________________________________________________________________

____________, a corporate surety authorized to transact insurance business in the State of Arizona, as surety, do

hereby bind ourselves, our heirs, executors, administrators and successors, jointly and severally to pay to the

State of Arizona the sum of one thousand dollars ($1,000) lawful money of the United States in the event that the

aforesaid Principal fails to comply with any or all conditions of this bond.

This bond, drawn and executed in the manner prescribed by A.R.S. §§ 20-411(D) and 20-411.01(B), shall

remain in force until released by the Director of Insurance or until terminated by the Surety. In accordance with

A.R.S. § 20-411(E) without prejudice to any liability previously incurred thereunder, the Surety may terminate this

bond upon thirty (30) days advance written notice filed with the Director of Insurance.

IN WITNESS WHEREOF, we have hereunto set our hands and affixed our seals this ______ day of

______________________, 19____.

________________________________________

(Signature of Principal)

Countersigned at:

________________________________________

(Print Name of Surety)

___________________________, Arizona

________________________________________

(Signature of Attorney-in-Fact)

_________________________________________________

Signature of Resident Agent (Other Than Principal)

(Surety's Power of Attorney Must Be Attached to this Bond)

(Affix Surety's Seal)

Form L-196MEX Ed. 06/97

Form L-196mex - Bond Of Mexican Insurance Surplus Lines Broker