Form E-700 (v. 20180727) Page 1 of 2 Attn: Surplus Lines Team Arizona Department of Insurance 100 North 15th Avenue, Suite 261 Phoenix, Arizona 85007-2630 Phone: (602) 364-3450 Email: ebows[email protected] Form E-700: Certificate of Surplus Lines Broker SECTION A: Entity Type Department of Insurance Use: Foreign Alien Lloyd’s Association Insurance Exchange Syndicate Each syndicate must file an annual financial statement in a form prescribed by the NAIC. SECTION B: Surplus Lines Insurer Information Insurance Exchange Name | Name: NAIC #: Exchange Syndicate Name | DBA Name U.S. State/Territory or Non-US Country Incorporated/Organized: Mailing Address: City: State: ZIP Code: SECTION C: Service of Process Information Enter information for the person to whom, pursuant to A.R.S. § 20-419, the Director of Insurance will forward legal process against the insurer. Name: Phone Number: Physical Street Address (must not be P.O. box): City: State: ZIP Code: SECTION D: Surplus Lines Broker Information Only an Arizona-licensed resident or non-resident surplus lines broker may file this Certificate. Broker Name: AZ Insurance License #: Contact Person – Name: E-mail Address: Title: Phone Number: SECTION E: Surplus Lines Broker Declaration 1. Syndicate of an insurance exchange – Enter the US state where the insurer is authorized to transact insurance on an admitted or surplus-lines basis. ARS § 20-413(E) 2. Insurance exchange – The insurance exchange must possess capital and surplus of at least $50,000,000, and each syndicate of the insurance exchange must possess capital and surplus of at least $5,000,000. Enter the amount of the insurance exchange’s capital and surplus AND enter the amount of the syndicate’s capital and surplus. ARS § 20-413(E)