Form Etransmt - Application Transmittal Form - Department Of Insurance Of State Of Arizona
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1Department of Insurance
State of Arizona
Financial Affairs Division
2910 NORTH 44TH STREET, SUITE 210
Phoenix, Arizona 85018-7256
Telephone: (602) 912-8420
Telecopier: (602) 912-8421
APPLICATION TRANSMITTAL FORM
AFFIX THIS FORM AS FIRST PAGE OF APPLICATION
Applicant Name
Address
Contact Person Name
Address
Collect/Toll Free Phone
Initial in space to left of each item and enter amounts. Enter “N/A” if not applicable.
Application is compiled with numbered tab dividers corresponding to Application Checklist.
Application Checklist enclosed and all items initialized or marked as “N/A.”
Fees Enclosed Separate Checks Required - Secure checks in a sealed envelope and staple to this form.
$
“Application Fees” from FORM EFEES
Payable to Arizona Department of Insurance
$
Fingerprint Card Processing Fees @ $24.00 each *
Payable to Arizona Department of Insurance
$
Foreign applicants only: Articles Filing Fee Payable
to Arizona Corporation Commission
$
100.00
New Admission Only: Examiners’ Revolving Fund
Deposit Payable to Insurance Examiners’ Revolving
Fund
Number of Fingerprint Cards enclosed =
*Fees above must reconcile with number of Cards and amount stated in Form EFEES Part B, Arizona Fees
column.
Completion of the information below will enable the Department to send correspondence regarding this application in
an expedited manner at the Applicant’s expense. If Applicant does not wish to pay for expedited delivery, all
correspondence will be sent by ordinary U.S. Mail.
Authorization is granted for expedited mailing via:
Courier Service Name:
Bill Account Number:
Account Name:
Addressee Name:
and Phone Number:
Street Address:
City, State Zip:
Authorizing Signature
Name and Title
Date
Form ETRANSMT (06/00)
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