Form L-168 - Application For An Individual Surplus Lines Broker License
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1
2
3APPLICATION FOR AN INDIVIDUAL SURPLUS LINES BROKER LICENSE (FORM L-168)
1. CAREFULLY READ THE ENCLOSED INSTRUCTIONS. Your application must be printed or typed.
2. Complete ALL PAGES of this form and fulfill all other requirements shown in the instructions.
3. Send application and fee payment together with other required materials to the following address:
INSURANCE LICENSING SECTION, 2910 North 44th Street, Suite 210, Phoenix, AZ 85018-7256
SECTION I: BUSINESS INFORMATION
A. (Legal) Last Name
B. Full First Name
C. Full Middle Name
D.
E.
Name of Business (if your
Will the business in box D receive
place of business is your
compensation for transactions under
your license (circle one):
YES
NO
home, enter “N/A”):
City:
State:
Zip Code:
F
.
Physical Business Street Address (*may not be P.O. box):
G.
City:
State:
Zip Code:
Address to appear on license (if left blank, box F address will appear on license)*:
H.
Business Area Code and Phone Number
SECTION II: LICENSE SELECTION
Write an “X” to the left of the license authority for which you are applying:
q
q
Surplus Lines Broker
Mexican Insurance Surplus Lines Broker
SECTION III: EMPLOYMENT HISTORY
List your employment history for the past five years (if none, please explain) and your insurance-related
experience during the past ten years. If more space is required, attach and sign a separate sheet containing the information.
EMPLOYMENT DATES
Employer Name
Type of Business
Position Held
City/State
FROM (mm/yy) TO (mm/yy)
SECTION IV: PERSONAL INFORMATION
MM
DD
YY
A.
B
C
q
q
. Date
. Place of
City:
State:
Male
Female
Sex:
of Birth:
Birth:
D
E
. Social Security Number [required by A.R.S. § 25-320(L)]:
. Home Area Code and Phone Number:
F
City
State
Zip Code
. Physical Address of Applicant’s Home
SPACE BELOW IS FOR INSURANCE DEPARTMENT USE ONLY
License Type: ____________________ License Number: _______________
Issued Date:_____/_____/______
Expiration Date: _____/_____/______
Exam Passed: _____/_____/______
_____________________________
____________________________
Approved for Licensing by: ________________________________________
#
$
#
$
CONTINUED ON THE FOLLOWING PAGE
Form L-168 (Eff. 07/00)
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Parent category: Legal