Form L-107 - Affidavit Of Managing General Agent
ADVERTISEMENT
1
2INSURANCE LICENSING SECTION
2910 NORTH 44TH STREET, SUITE 210
FORM L-107
PHOENIX, ARIZONA 85018-7256
AFFIDAVIT OF MANAGING GENERAL AGENT
THIS DOCUMENT MUST BE COMPLETED BY AN OFFICER OF THE INSURANCE COMPANY (the “Insurer”) named in
Section I below. The completed affidavit must be included with the license application of the prospective managing
general agent.
Full name of the INSURER the MGA named in Section B will represent:
NAIC
SECTION A
Number
Street address of insurer
City
State
Zip Code
Insurer
Information
Full name of the MGA which will represent the insurer named in Section A:
SECTION B
Street address of MGA
City
State
Zip Code
MGA
Information
SECTION C
Does or will the MGA named in Section B:
Scope of MGA
1.
EITHER
q
q
Yes
No
Responsibilities
a.
Negotiate and bind ceding reinsurance contracts on
behalf of the insurer in Section A (“Insurer”)?
q
q
OR
Yes
No
b.
Manage all or part of the insurance business of the
Insurer, including the management of a separate
division, department or underwriting office?
q
q
2.
AND act as an agent for the Insurer?
Yes
No
3.
AND produce and underwrite, with or without authority and
either separately or together will affiliates, directly or
indirectly, an amount of gross direct written premium that is
q
q
equal to or exceeds 5% of the policyholder surplus as
Yes
No
reported in the last annual statement of the Insurer in any
one quarter or year?
4.
AND EITHER
q
q
Yes
No
a.
engage in the adjustment or payments of claims
OR
q
q
Yes
No
b.
negotiate reinsurance on behalf of the Insurer?
CONTINUED ON THE FOLLOWING PAGE
Page 1 of 2
Form L-107 (Eff. 01/98)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal