Fillable Financial Affairs Division Arizona Department of Insurance REQUEST (Arizona)

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Financial Affairs Division Arizona Department of Insurance REQUEST (Arizona)

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Form E126CD (v. 20180824)
Financial Affairs Division
Arizona Department of Insurance
100 North 15
th
Avenue, Suite 102, Phoenix, Arizona 85007-2624
Phone: (602) 364-3999
Web: https://insurance.az.gov/
REQUEST FOR RELEASE OF CERTIFICATE OF DEPOSIT
REQUEST IS MADE FOR RELEASE OF THE FOLLOWING CERTIFICATE OF DEPOSIT FROM
SAFEKEEPING WITH THE ARIZONA STATE TREASURER ON BEHALF OF THE DIRECTOR OF
INSURANCE, WHO IS, IN TURN, HOLDING THE SECURITY FOR:
fe
(Complete Name of Company) (NAIC / AZ CO #)
CERTIFICATE OF DEPOSIT DESCRIPTION:
Name of Financial Institution:
Face Amount:
$
Interest Rate:
%
Maturity Date:
Certificate of Deposit Number:
Financial Institution Account Number:
(if different than CD Number)
TO BE CLASSIFIED AS A: (Check one only)
HCSO Escrow Reserve Deposit - ARS § 20-1056
Ordinary Statutory Deposit required for authority to transact in Arizona
Retaliatory Deposit – ARS § 20-230
Security Deposit for the benefit of ARIZONA policyholders only
Workers’ Compensation Deposit – ARS § 23-961
INSTRUCTIONS FOR DELIVERY OF THE RELEASED CERTIFICATE ARE:
Recipient Name and Title:
Company or Firm Name:
Street Address:
City, State, Zip:
BY THIS AUTHORIZED REPRESENTATIVE OF THE COMPANY: (authorizing resolution may be required)
Name:
Title:
Signature:
Date:
CONTACT PERSON:
Title:
Telephone number:
Email:
DELIVER THIS FORM TO THE ADDRESS SHOWN ABOVE.
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Financial Affairs Division Arizona Department of Insurance REQUEST (Arizona)

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Completed 12 August 2020

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