Form L-193 - Certificate Of Assumed Business Name printable pdf download

INSURANCE LICENSING SECTION

2910 NORTH 44TH STREET, SUITE 210

PHOENIX, ARIZONA 85018-7256

FORM L-193

CERTIFICATE OF ASSUMED BUSINESS NAME

Select one of the following: New

(not previously filed)

Change

(previously filed but reporting a change of address)

ASSUMED NAME:

FULL GENUINE NAME OF LICENSEE:

AZ INSURANCE LICENSE #:

Business (Physical) Street Address

Mailing Address

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

NOTE: Pursuant to A.R.S. § 20-318(A), if under the assumed name insurance shall be transacted in one

or more locations that are not shown above, a signed and dated list of all additional locations where

insurance is to be transacted must be attached.

The FULL true or real name of each person owning, conducting or transacting insurance under this certificate must be listed below. If

additional space is required, a signed and dated list must be attached.

ACKNOWLEDGMENT AND CERTIFICATION

As the person or persons conducting or intending to conduct insurance under the assumed name on this

Certificate, by my/our signature(s) below and on the reverse, I/we hereby acknowledge and certify:

That, in accordance with A.R.S. § 20-318(B), an updated CERTIFICATE OF ASSUMED BUSINESS NAME

must be submitted upon

• the change of the genuine or assumed name of any individual or entity provided in this Certificate, or

• if pertaining to the license of an individual, the change of the address of his/her residence, or

• the change, addition or elimination of the address of any place of business where the assumed name

shown on this Certificate is being used, or

• the addition of any person owning, conducting or transacting insurance under this certificate.

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.

• the name would tend to deceive or mislead as to the nature of the business that is or will be conducted.

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: ____/____/_____

___________________________________

________________________________

ADDITIONAL SIGNATURES MAY BE AFFIXED ON THE REVERSE

Form L-193 (Effective 01/98)

Form L-193 - Certificate Of Assumed Business Name

Related Articles

Related forms

Related Categories