Form L-176 - Application For A License For Firm Or Corporation

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Arizona Department Of Insurance
FORM L-176
APPLICATION FOR A LICENSE FOR FIRM OR CORPORATION
1. CAREFULLY READ THE ENCLOSED INSTRUCTIONS. Your application must be printed or typed.
2. Complete BOTH SIDES of this form and fulfill all other requirements shown in the attached instructions.
Send application and fee payment together with other required materials to the following address:
3.
INSURANCE LICENSING SECTION, 2910 North 44th Street, Suite 210, Phoenix, AZ 85018-7256
SECTION I: BUSINESS INFORMATION
Full Name of Applicant
Physical street address* of business (may not be P.O. box)
City
State
Zip Code
Mailing address to appear on license (if blank, the physical address will appear on license)*
City
State
Zip Code
Telephone Number
* The physical street address may not be a post office box. The mailing address may be a post office box if desired.
NOTE: If the applicant shall transact business at locations other than the physical address identified in Section I,
(
)
-
applicant must attach a signed and dated list of the other locations and, for each location, listing the name and
Arizona insurance license number of each person who will transact insurance on behalf of the applicant.
SECTION II: INSURANCE COMPANY INFORMATION
As required by A.R.S. § 20-291(E), in the left column below, list the EXACT, FULL
NAMES of all Arizona-admitted insurance companies (carriers/underwriters) you are authorized to represent subject to the issuance of the license for which you are
applying. Write the NAIC number for each (can be obtained from the insurance company). If applying for a license as broker or adjuster, write “N/A”
EXACT, FULL NAME OF INSURANCE COMPANY (If more space is required, attach a list)
NAIC Number
1,
2.
3.
SECTION III: LICENSE SELECTION
Write an “X” to the left of the license authority for which you are applying:
q
q
q
q
Life Agent
Property & Casualty Agent
Broker
Property & Casualty
Managing General Agent
q
q
q
q
Disability (Accident & Health)
Title Agent
Adjuster
Life Managing General
Agent
Agent
q
q
q
Variable Contracts Agent
Bail Bond Agent
Disability Managing General
Agent
SECTION IV: PRINCIPALS OF THE FIRM/CORPORATION
List the names and titles of the firm's principals, including all owners with a 10%
or greater share of voting rights excluding ownership in publicly traded securities, directors and officers if a corporation, partners if a partnership, members and managers
if a limited liability company, trustees if a trust, and owners, stockholders and employees if for a bail bond agent license. Attach a signed and dated list if additional space
is needed.
Name:
Title:
Name:
Title:
Name:
Title:
SECTION V: LICENSED REPRESENTATIVES OF APPLICANT
List the FULL names and Arizona insurance license numbers of all
individuals who are to exercise the powers conferred by the license. If additional space is required, attach a signed and dated list.
Name:
AZ License #
Name:
AZ License #
Name:
AZ License #
r
SPACE BELOW IS FOR INSURANCE DEPARTMENT USE ONLY
License Type(s): ______________________________________
License Number: ___________________
Issue Date: _____/____/_____Expiration Date: ____/_____/_____
#
$
#
$
CONTINUED ON THE FOLLOWING PAGE
L-176 (Eff. 01/2001)

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