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approval from the Corporation Commission, submit with the license application a copy of the

filed and numbered approval.

If organized in Arizona or holding foreign authority for more than one year when the

application is filed, attach a copy of the latest filed “Certificate of Disclosure” or an original

“Certificate of Good Standing” from the Arizona Corporation Commission as evidence that

the applicant is in good standing.

General partnership applicant must submit with the application a copy of the written partnership

agreement which has been stamped as “recorded” in the office of an Arizona county recorder, or if

organized outside Arizona, stamped as “recorded” with the official office in which the partnership was

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

of the agreement.

Limited partnership (residents and nonresidents) applicant must submit with the application a copy

of the certificate of registration from the Arizona Secretary of State.

10.

Business trust applicant must include a copy of the filed and recorded trust agreement.

11.

Assumed Name (or Trade Name or DBA). If the license is to be issued in a “trade name,” the

name must be lawfully registered with the Arizona Secretary of State [at (602) 542-6187]. A.R.S. §

20-411(F)(2).

12.

If you answered “YES” to any question in Section V, you are required to submit

a SIGNED and NOTARIZED statement describing in detail all incidents including (1) names

of all parties involved, (2) dates and locations, (3) the names and localities of any courts

and/or administrative agencies involved, (4) the disposition of each matter, (5) whether the

conviction, plea or finding was for a felony, misdemeanor or open-ended charge; AND

certified copies of any and all indictments, complaints, plea agreements, orders of conviction,

notices of hearing or trial, sentencing orders, suspension/revocation orders and any other

information which relates to each matter. If certified copies are not available, you must

provide as a part of this application a letter from the clerk of the pertinent court or the official

involved stating the records are not available and the reason.

•

NOTE: It is illegal for an individual convicted of a felony involving dishonesty, of a

felony involving breach of trust or of violating the Violent Crimes and Control Act of

1994 (18 U.S.C. 1033) to work or continue to work in the business of insurance without

receiving written consent from the Director of Insurance. Persons that employ, contract

with or otherwise utilize individuals in conjunction with the business of insurance must

exercise due diligence in identifying those persons for whom the Director's written

consent must be obtained.

THE ARIZONA DEPARTMENT OF INSURANCE IS AN EQUAL EMPLOYMENT OPPORTUNITY AGENCY WHICH COMPLIES WITH THE AMERICANS WITH DISABILITIES ACT OF 1990

APPLICATION FOR A SURPLUS LINES BROKER LICENSE FOR A FIRM/CORPORATION

INSTRUCTIONS: FORM L-176/SLB (Eff. 01/2001)

Instructions For Form L-176/slb - Application For A Business-Entity Insurance License Page 2