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: ebowsher@azinsurance.gov

Form E-700: Certificate of Surplus Lines Broker

SECTION A: Entity Type Department of Insurance Use:

Foreign Alien Lloyd’s Association Insurance Exchange SyndicateEach 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)

Form E-700: Certificate of Surplus Lines Broker

Form E-700 (v. 20180727) Page 2 of 2

3. The Insurer maintains a deposit in public custody in trust for the purpose of protecting all ofthe Insurer’s policyholders in the United States pursuant to ARS § 20-413Insurance exchange – The insurance exchange must maintain a deposit of at least$2,500,000 in public custody in trust for the purpose of protecting all the insurer’spolicyholders in the U.S. Enter the amount of the deposit that the insurance exchangemaintains and the state within the U.S. that has custody of the deposit.

SECTION F: Required Enclosures

1. ENCLOSE Form E-701 completed by theSyndicate of an insurance exchange – U.S. insurance supervisory official with whom the required trust fund ismaintained.

SECTION G: Surplus Lines Broker Attestation If the surplus lines broker is a business entity, this attestation must be executed by the designated responsible licensed producer (“DRLP”) of the broker.

All information contained in this Certificate is true and correct to the best of our knowledge and belief.

_______________________________________ _____________________________ ________________ Signature of Broker Printed Name of Broker or DRLP Date