Arizona Agent Form PDF Details

Arizona has specific requirements for insurance agents. In order to become an agent in Arizona, you must fill out and submit a specific form to the state. The form is called the Arizona Agent Form, and it must be completed in its entirety. Failure to do so may result in your application being denied. Make sure you are familiar with all of the information included on the form before submitting it. You can find a copy of the form on the Arizona Department of Insurance website.

QuestionAnswer
Form NameArizona Agent Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesstatutory agent acceptance form m002, statutory agent acceptance form, form m002 arizona, m002 az

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DO NOT WRITE ABOVE THIS LINE; RESERVED FOR ACC USE ONLY.

STATUTORY AGENT ACCEPTANCE

Please read Instructions M002i

1.ENTITY NAME – give the exact name in Arizona of the corporation or LLC that has appointed the Statutory Agent (this must match exactly the name as listed on the document appointing the statutory agent, e.g., Articles of Organization or Article of Incorporation):

____________________________________________________________________________

2.STATUTORY AGENT NAME – give the exact name of the Statutory Agent appointed by the entity listed in number 1 above (this will be either an individual or an entity). NOTE - the name must match exactly the statutory agent name as listed in the document that appoints the statutory agent (e.g. Articles of Incorporation or Articles of Organization), including any middle initial or suffix:

_____________________________________________________________________

3.STATUTORY AGENT SIGNATURE:

By the signature appearing below, the individual or entity named in number 2 above accepts the appointment as statutory agent for the entity named in number 1 above, and acknowledges that the appointment is effective until the appointing entity replaces the statutory agent or the statutory agent resigns, whichever occurs first.

The person signing below declares and certifies under penalty of perjury that the information contained within this document together with any attachments is true and correct, and is submitted in compliance with Arizona law.

SignaturePrinted NameDate

REQUIRED – check only one:

Individual as statutory agent: I am

Entity as statutory agent: I am signing on

signing on behalf of myself as the individual

behalf of the entity named as statutory agent,

(natural person) named as statutory agent.

and I am authorized to act for that entity.

Filing Fee: none (regular processing) Expedited processing – not applicable.

All fees are nonrefundable - see Instructions.

Mail: Arizona Corporation Commission - Corporate Filings Section

1300 W. Washington St., Phoenix, Arizona 85007

Fax: 602-542-4100

Please be advised that A.C.C. forms reflect only the minimum provisions required by statute. You should seek private legal counsel for those matters that may pertain to the individual needs of your business.

All documents filed with the Arizona Corporation Commission are public record and are open for public inspection. If you have questions after reading the Instructions, please call 602-542-3026 or (within Arizona only) 800-345-5819.

M002.003

Arizona Corporation Commission – Corporations Division

Rev: 9/2014

Page 1 of 1

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arizona statutory agent acceptance form m002 completion process shown (part 1)

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arizona statutory agent acceptance form m002 completion process explained (part 2)

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