Form L-169 - Application For An Individual Insurance License - State Of Arizona
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1
2
3APPLICATION FOR AN INDIVIDUAL INSURANCE LICENSE (FORM L-169)
1. CAREFULLY READ THE ENCLOSED INSTRUCTIONS. Your application must be printed or typed.
2. Complete ALL PAGES of this form and fulfill all other requirements shown in the attached instructions.
3. Send your application and fee payment together with other required materials to the following address:
INSURANCE LICENSING SECTION, 2910 North 44th Street, Suite 210, Phoenix, AZ 85018-7256
SECTION I: BUSINESS INFORMATION
C. Full Middle Name
A
B
.
(Legal) Last Name
. Full First Name
*If your mailing address contains the name of a
D.
Name of Business (if your
business and you share commissions with it,
place of business is your
that business must be separately licensed.
home, enter “N/A”)*:
City:
State:
Zip Code:
E
.
Physical Street Address of Place of Business (*may not be a P.O. box):
City:
State:
Zip Code:
F.
Mailing address (P.O. box permitted. iIf blank, Box E address will print on license):
G.
Business Area Code and Phone Number
SECTION II: INSURANCE COMPANY INFORMATION
As required by A.R.S. § 20-291(E), in the left column below, list the EXACT, FULL
NAMES of all Arizona-admitted insurance companies (carriers/underwriters) you are authorized to represent subject to the issuance of the license for which you
are applying. To the right of each insurance company, write its NAIC number which can be obtained from the insurance company. If only applying for a license
”
as broker, adjuster or risk management consultant, write “N/A
EXACT, FULL NAME OF INSURANCE COMPANY (If more space is required, attach a list)
NAIC Number
1,
2.
3.
SECTION III: LICENSE SELECTION
Write an “X” to the left of the license authority for which you are applying:
q
q
q
q
Property & Casualty Agent
Bail Bond Agent
Risk Management Consultant
Property & Casualty
Managing General Agent
q
q
q
q
Life Agent
Travel Agent, Limited
State Compensation
Life Managing General
Marketing Representative
Agent
q
q
q
q
Disability (Accident &
Broker
Service Representative
Disability Managing
Health) Agent
General Agent
q
q
Variable Contracts Agent
Adjuster
SECTION IV: PERSONAL INFORMATION
M
D
Y
A.
B
C
q
q
. Date
.Place
City:
State:
Male
Female
Sex:
of Birth:
of Birth:
D
E
. Social Security Number [required by A.R.S. § 25-320(L)]:
. Home Area Code and Phone Number:
City
State
Zip Code
F
. Physical Address of Applicant’s Home
r
SPACE BELOW IS FOR INSURANCE DEPARTMENT USE ONLY
_________exam passed on ____/____/_____
License #: ________________
_________exam passed on ____/____/_____
Exp. Date: _____/_____/_____
_________exam passed on ____/____/_____
_____________________________
__________________________
Issue Date: _____/_____/_____
Kinds Issued: _________________________
_
#
$
#
$
CONTINUED ON THE FOLLOWING PAGE
Page 1 of 3
Form L-169 (Eff. 07/2000)
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