Form E-Certreq - Certificate Request Form

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Financial Affairs Division
Arizona Department of Insurance
th
2910 North 44
Street, Suite 210, Phoenix, Arizona 85018-7269
Phone: (602) 364-3245 Email:
amccormack@azinsurance.gov
Web:
https://insurance.az.gov
Reset Form
CERTIFICATE REQUEST FORM
S
A
ECTION
: I
C
I
NSURANCE
OMPANY
NFORMATION (
)
SUBMIT ONE FORM PER COMPANY
I
C
N
:
S
D
:
NAIC N
:
NSURANCE
OMPANY
AME
TATE OF
OMICILE
UMBER
S
B
ECTION
: C
I
ERTIFICATE
NFORMATION
T
C
:
Q
:
C
:
P
:
YPES OF
ERTIFICATE
UANTITY
OST
RICE
0.00
$3.00
* Certificate of Authorization & Deposit
0.00
$3.00
Certificate of Valuation
(Life Companies Only)
0.00
$3.00
* UCAA Certificate of Deposit
(Excludes Companies with WC)
0.00
$3.00
UCAA Certificate of Compliance
(Domestic Only)
:
MAKE CHECK PAYABLE TO
ARIZONA DEPARTMENT OF INSURANCE
0.00
(
)
TOTAL:
TO BE PAID PRIOR TO MAILING CERTIFICATES
* S
C:
ECTION
*______________
E
:
(E
: 12/31/2016
C
)
FFECTIVE DATE REQUESTED FOR ABOVE
XAMPLE
OR
URRENT
S
D
ECTION
:
C
ONTACT INFORMATION
:
CONTACT
C
:
OMPANY
A
:
DDRESS
C
,
,
ITY
STATE
ZIP
P
:
HONE
E
:
MAIL
F
-X
ED
[
R
]
ECOMMENDED
UPS
NO LONGER AN OPTION
PICKUP
NOTE: ENCLOSE SHIPPING LABEL OR AN ACCOUNT NUMBER FOR FED-X
(CERTIFICATE(S) WILL BE SENT BY REGULAR MAIL IF FED-X SHIPPING LABEL OR ACCOUNT NUMBER
IS NOT ENCLOSED OR LISTED)
Form E-CERTREQ (v. 20170418)

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