Form E-Preadmitcklst - Preadmission Examination Records Request - Department Of Insurance Of State Of Arizona
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1
2Department 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
PREADMISSION EXAMINATION RECORDS REQUEST
COMPANY NAME
ADDRESS
CITY, STATE, ZIP
CONTACT PERSON(S):
Name:
Address:
Phone:
Fax:
E-Mail:
The following is a list of the additional documentation that must be filed within a new domestic insurance company
application for certificate of authority to enable the Department to perform a Preadmission Examination in accordance
with A.R.S. § 20-156(B). Failure to provide this documentation will delay issuance of the Arizona Certificate of
Authority.
Use this Form as a checklist to compile the required records. Initial each item as enclosed, or enter “NA” if not
applicable. File this Form as the first item under a tab or divider labeled as “AZS.5” in response to the Arizona State
Specific Requirements for a UCAA Primary Application.
CORPORATE RECORDS:
INITIAL or “NA”
Minutes and any Resolutions (inception to date) of the:
Incorporators
Shareholders
Directors
Any Committees
Capital stock register
Stock Certificates issued and outstanding
Surplus notes or Contribution Agreements
Holding Company System: If not disclosed in the Holding
Company Form “B” Registration Statement (or its equivalent):
Describe in detail the source, nature and amount of
funds to capitalize the Applicant
Any/all agreements relating to surplus note transactions
Principal business of all affiliates
Directors of all affiliates
A written statement of the location in Arizona where books
and records will be maintained
Conflict of interest procedure and disclosure statements
Employment agreements
Insurance policies maintained (including fidelity bond)
Description and copy of any lease, lease/purchase commitment,
and/or contract that encumbers assets or incurs liabilities
REINSURANCE RECORDS:
Each proposed agreement
Any trust agreements
Any letters of credit
E-PREADMITCKLST (06/00)
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