Form Adj.addendum-Addendum To Adjuster Application For Nonresidents October 2003

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INSURANCE LICENSING SECTION
2910 NORTH 44TH STREET, SECOND FLOOR
PHOENIX, ARIZONA 85018-7256
(602) 912-8470 / (877) 660-0964
ADDENDUM TO ADJUSTER APPLICATION FOR NONRESIDENTS
Pursuant to the requirements of Arizona Revised Statutes § 20-321.01(C)(4), adjusters
must maintain in this State an office accessible to the public and keep therein the usual and
customary records pertaining to transactions under an adjuster’s license.
Enter below the street address and telephone number of the location within Arizona that
is accessible to the public and at which records pertaining to adjuster transactions are
maintained.
FULL NAME OF APPLICANT:
Street Address
LOCATION
City
State
Zip Code
Telephone
ADDRESS
(
)
--
AZ
_______________________________________________
Full Signature of Applicant (
or if for a firm/corporation, authorized representative)
(FULL first, middle and last names)
Form ADJ.ADDENDUM (Effective 10/2003)

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