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INSTRUCTIONS FOR FORM L-176/SLB

This application is for Surplus Lines Brokers and Mexican Insurance Surplus Lines Brokers. For other insurance licenses, use Form L-176.

Carefully read all instructions prior to completing your application. Incomplete application

submissions will result in the rejection of your application. To obtain additional assistance, call the

Insurance Licensing Section at (602) 912-8470, or visit our web site at

Clearly print or type all information except signatures.

Fees. You are required to pay a NON-REFUNDABLE fee [A.R.S. § 20-167(G)] made payable to

INSURANCE LICENSING SECTION with your license application. The following fees shall be in

effect through June 30, 2001:

If you do not already hold an Arizona insurance license, the license fee shall be $500.00.

If you already hold an Arizona insurance license and you file your application for additional

license line(s)/type(s) in the first half of the biennial term of your existing license, the license

fee shall be $500.00.

If you already hold an Arizona insurance license and you file your application for additional

license line(s)/type(s) in the second half of the biennial term of your existing license, the

license fee shall be $250.00.

Bond requirements. A surety bond executed on Form L-196 in the sum of $25,000 is required of

surplus lines brokers (resident and nonresident). A surety bond executed on Form L-196MEX in the

sum of $1,000 is required of Mexican insurance surplus lines brokers. The surety bond must be

accompanied by the surety’s power of attorney.

Examination requirements for residents. Except for Mexican Insurance Surplus Lines Broker

applicants, at least one individual in each office or place where insurance is transacted must be

licensed as an insurance agent or broker pursuant to Title 20, Arizona Revised Statutes, and must

have passed the surplus lines broker examination. The examination requirement applies only to

residents. A.R.S. §§ 20-411(G) and 20-411.02(A).

A nonresident applicant must hold a surplus lines license in the resident state. Submit an original

certification executed by the insurance department located in the state in which the applicant holds

the resident insurance license. The certification must be dated within three months of the

Department’s receipt of the application.

Corporation and limited liability company applicant must:

Submit with the application a copy of the articles of incorporation or articles of

organization which were stamped as “filed’ with the Arizona Corporation Commission or, if

organized outside Arizona, stamped as “filed” with the official office in which incorporation was

effected.

The business to be transacted subject to issuance of the license must be within the scope of

the articles.

If organized outside Arizona, obtain from the Arizona Corporation Commission [at (602) 542-

3135] an “Application for Authority to Transact Business in Arizona.” After receiving

Instructions For Form L-176/slb - Application For A Business-Entity Insurance License