Form L-169 - Application For An Individual Insurance License

SECTION VIII: AUTHORIZATION AND RELEASE

Read the following, sign this page and have this page notarized.

I understand that pursuant to A.R.S. § 20-304, application for and acceptance of a nonresident license constitutes

an irrevocable appointment of the Director of insurance as attorney of the licensee for the acceptance of service of

process issued in this state in any action or proceeding against the licensee arising out of such licensing or out of

transactions under the license. Process service on the director on behalf of a nonresident licensee constitutes service

on the licensee as though the licensee were personally served with process in this state.

Having filed this application, I hereby consent to having an investigation made of my moral character, professional

reputation and fitness for an insurance license. I agree to give any further information that may be required in

reference to my past record.

I also authorize and request every person, firm, company, corporation, governmental agency, court, association or

institution having control of any documents, records and other information pertaining to me to furnish the Arizona

Department of Insurance with any such information including documents, records, insurance department files

including charges or complaints filed against me, formal or informal, pending or closed, or any other pertinent data,

and to permit the Arizona Department of Insurance, or any of its agents or representatives or my authorized insurers

to inspect and make copies of such documents, records and other information.

I release, discharge, and exonerate the Arizona Department of Insurance, its agents and representatives, the

State of Arizona, my authorized insurers, and any person furnishing information pursuant to this Authorization and

Release from and all liability which may arise from the investigation made by the Arizona Department of Insurance.

AFFIDAVIT OF VERIFICATION

STATE OF:

)

COUNTY OF:

)

Being first duly sworn, applicant deposes and says that he/she has read the foregoing, and each statement and

answer made, together with the Authorization and Release and under penalty of perjury, swears that all such

answers, statements and data attached to this application are true and correct.

__________________________________________________

Full Signature of Applicant

(include FULL first, middle and last names)

SUBSCRIBED AND SWORN TO before me this _______ day of ____________________, ________.

________________________________

Notary Public

(SEAL)

My commission expires: ____________

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Form L-169 - Application For An Individual Insurance License - State Of Arizona Page 3