Form L-193 - Certificate Of Assumed Business Name
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1INSURANCE LICENSING SECTION
2910 NORTH 44TH STREET, SUITE 210
PHOENIX, ARIZONA 85018-7256
CERTIFICATE OF ASSUMED BUSINESS NAME
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Select one of the following:
New
q (previously filed but reporting a change)
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FULL GENUINE NAME OF LICENSEE:
AZ INSURANCE LICENSE #:
ASSUMED NAME:
Business (Physical) Street Address
Mailing Address (optional)
City
State
Zip Code
City
State
Zip Code
Physical Street Address of Residence (if an individual licensee)
Business Area Code and Telephone Number
City
State
Zip Code
Residence Area Code and Telephone Number
E-mail Address (optional)
Fax Area Code and Telephone Number (optional)
ACKNOWLEDGMENT AND CERTIFICATION
As the person conducting or intending to conduct insurance under the assumed name on this Certificate, or as two
of the owners, officers, directors, partners, trustees or LLC members/managers of a firm or corporation which is
conducting or intends to conduct insurance under the assumed name on this Certificate, by my/our signature(s)
below, I/we hereby acknowledge and certify:
1)
That, in accordance with A.R.S. § 20-297, a licensee must submit an updated CERTIFICATE OF ASSUMED
BUSINESS NAME before doing business under any name other than the licensee's legal name;
2)
That the Director of Insurance may deny the use of an assumed business name, require the use of a different
assumed business name or required the use of an assumed business name under this section if
• the name is so similar to that of any firm, corporation or other entity already licensed or using an assumed
name under a duly filed CERTIFICATE OF ASSUMED BUSINESS NAME as to cause uncertainty or
confusion, or
• the name would tend to deceive or mislead as to the nature of the business that is or will be conducted;
3)
That the licensee must notify the Insurance Department in writing within 30 days after any material change to
the information provided on this form.
4)
That the filing of this certificate does not legally reserve the assumed business name as a trade name*.
*NOTE: A trade name can be reserved with the Office of the Arizona Secretary of State if business will be transacted from an
Arizona location. If you have received a Trade Name Certificate from the Arizona Secretary of State, please attach it to this
Certificate.
Signature: __________________________________
Printed Name:_______________________________
Date: ____/____/_____
Signature: __________________________________
Printed Name:_______________________________
Date: ____/____/_____
Form L-193 (Rev. 12/2001)
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Parent category: Legal