Form Sl-111 Certificate Of Public Supervisory Official
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1***A.R.S. § 20-413(F) CERTIFICATE OF PUBLIC SUPERVISORY OFFICIAL***
TO BE RETURNED BY THE SURPLUS LINES BROKER TO THE: PROPERTY/CASUALTY DIVISION
STATE OF ARIZONA -- DEPARTMENT OF INSURANCE
2910 NORTH 44TH STREET - SUITE 210
PHOENIX, AZ 85018-7269
TELEPHONE: (602) 364-3453; FACSIMILE: (602) 364-3989
SECTION I (Certificate Of Deposit, Capital And Surplus):
For the purposes of this document, "insurer" means any of the following: a foreign insurer, an alien insurer, a Lloyds association, and
insurance exchange or any member syndicate of an insurance exchange.
CERTIFICATE OF DEPOSIT, CAPITAL AND SURPLUS:
I, _______________________________________________ (COMPLETE NAME AND TITLE OF PUBLIC OFFICIAL) do hereby certify that I am
the public official or other person having supervision over insurers in the State of _______________ and that (check that which applies and complete
A, B, or C below):
___
A.
_________________________________________ (COMPLETE NAME OF INSURER) is an insurer organized under the laws of
this State and is located at ________________________________. The aforementioned insurer possesses capital and surplus of at least $15,000,000.
The aforementioned insurer possessed for the year ending, December 31, ____, capital and surplus of $_____________. (To be entered from line 37,
page 3, column 1 (Current Year) of the insurer's N.A.I.C. Annual Statement.)
___
B.
_________________________________________ (COMPLETE NAME OF INSURER) is an insurance exchange organized under
the laws of this State and is located at ________________________________. The member syndicates of the exchange possess aggregate capital and
surplus of at least $50,000,000, (to be taken from Line 25, Column 1, of the exchange's N.A.I.C. Annual Statement) and the exchange maintains a
deposit with a current market value of at least $2,500,000 in public custody in this State in trust for the purpose of protecting all the exchange's
policyholders in the United States.
The aforementioned exchange possessed for the year ending, December 31, ____, capital and surplus of
$_____________. (To be entered from line 32, page 3, column 1 (Current Year) of the insurer's N.A.I.C. Annual Statement.)
___
C.
_________________________________________ (COMPLETE NAME OF INSURER) is a syndicate which is a member of the
_____________________________ insurance exchange. The aforementioned member of exchange is organized under the laws of this State and is
located at ________________________________ and possesses capital and surplus of at least $5,000,000.
In witness thereof, I subscribe my name and affix the seal of my
Office hereto this ________ day of ________________, 20____
SEAL
______________________________________
(SIGNATURE OF PUBLIC SUPERVISORY OFFICIAL)
Telephone Number:_________________
The above document must be accompanied by a certificate of compliance or other acceptable proof of the extent of this insurer’s authority to
transact insurance in the state of domicile. In the case of a syndicate, the above form must be completed for each syndicate within the
insurance exchange that intends to transact insurance in Arizona.
SECTION II (Certificate Of Deposit):
This section is to be completed by a public insurance official or other person having supervision over insurers of a state in which the insurer
maintains a deposit and which state is not the insurer's state of domicile.
CERTIFICATE OF DEPOSIT:
I, _______________________________________________ (COMPLETE NAME AND TITLE OF PUBLIC OFFICIAL) do hereby certify that I am the
public official having supervision over insurers in the State of ____________________ and that____________________________________________
__________________________ (COMPLETE NAME OF INSURER) is an insurer domiciled in the State of _____________. The aforementioned
insurer maintains a deposit with a current market value of at least $________________ in public custody in this State in trust for the purpose of
protecting all the insurer's policyholders in the United States.
In witness thereof, I subscribe my name and affix the seal of my
office hereto this ________ day of _______________, 20 ____
SEAL
______________________________________________
(SIGNATURE OF PUBLIC OFFICIAL OR OTHER SUPERVISORY OFFICIAL)
Telephone Number:_________________
ADOI SL FORM 111 (ED 07/21/2011)
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