Form L-141 - Bond Of Insurance Broker printable pdf download

INSURANCE LICENSING SECTION

2910 NORTH 44TH STREET, SUITE 210

PHOENIX, ARIZONA 85018-7256

BOND NUMBER: ____________________

BOND OF INSURANCE BROKER (FORM L-141)

I/We, __________________________________________________________, as Principal for an

Arizona Insurance Broker license and _________________________________________, as an admitted

surety insurer (“Surety”), bind ourselves to the penal sum of One Thousand Dollars ($1,000.00) to the

People of the State of Arizona. The total aggregate liability under this bond is limited to One Thousand

Dollars ($1,000.00).

The conditions of this obligation are such that if the Principal is granted a broker license, Principal

shall make full accounting and due payment to the person entitled thereto of funds coming into the

Principal’s possession as an incident to insurance transactions under the license.

This bond shall remain in force as prescribed by Arizona Revised Statutes § 20-299 until released by

the Director of Insurance or until canceled by the Surety. Without prejudice to any liability previously

incurred thereunder, the Surety may cancel the bond upon thirty (30) days advanced written notice filed with

the Director of Insurance.

Dated this _______ day of ____________________,

__________________________________________

Full Signature of Principal (Broker)

(including FULL first, middle and last names)

__________________________________________

Full Name of Surety Insurer

By:

__________________________________________

Attorney-in-fact

Countersigned at:

(Affix Surety

________________________________ (City/State)

company seal)

_______________________________________

Signature of Surety’s Agent

(Other Than Principal)

Any surety company duly authorized to transact insurance business in the State of Arizona may become

Surety on this bond.

This bond must be countersigned by a licensed resident Arizona agent of the surety company. A power of

attorney must be attached to this bond. This bond must be signed by the Principal and the Surety’s

attorney-in-fact.

Form L-141 (Effective 02/99)

Form L-141 - Bond Of Insurance Broker