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Public Record Request

Please select the type of records requested: (select all that apply)

Insurance Company

Financial Institution or Enterprise (Banks, Credit Unions, Consumer Lenders, Mortgage Bankers, etc.)

Licensing Documents (new and renewal applications, amendments to licensee data, etc.)

Licensee lists Financial Institutions and Financial Enterprises

Complaint: Insurance Company/ Professionals

Other (explain):

Please explain your request for public records

Please describe the record(s) requested:

Provide as much information as possible including the names (producer, business, insurance company, financial institution, financial enterprise), license numbers and a range of dates for the records requested.

Commercial purpose question: Do you or does anyone for whom you are acting as an agent intend to do any of the following with the public document(s) you are requesting.
Definition of Commerical Purpose

Use the names and addresses from the public record for the purpose of solicitation?

Use the public record for the purpose of sale or resale or for the purpose of producing a document containing all or part of the copy, printout or photograph for sale?

Sell the names and addresses to another for the purpose of solicitation or for any purpose in which the purchaser can reasonably anticipate the receipt of monetary gain from the direct or indirect use of the public record?

You have answered “Yes” to any of the preceding questions, your request is for a “COMMERCIAL PURPOSE.”

COMMERCIAL PURPOSE does not include the use of a public record as evidence or as research for evidence in any action in any judicial or quasi-judicial body. Pursuant to Arizona law, briefly describe the specific commercial purpose in the space below:

I am requesting that copies of this information be sent by

mail

I am requesting certified copies

Requestor's Name

Email Address

Confirm email

Phone

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

CERTIFICATION: I have read and understand this form, including the provisions listed on the initial Public Records page found on the DIFI.Az.Gov. I certify that the information I have provided in this form is true and correct and that the records will not be used directly or indirectly for any purpose other than described above. I understand that I am responsible for paying all fees associated with this request before the requested records will be provided.

Signature

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Public Record Request

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Public Records Request

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Public Record Request

Type of Request

Commercial Purpose

email, mail, certified

Certification

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Public Records Request