Note: After final submission of this form you will be provided with an opportunity to attach supporting documents
If mailing supporting documents, please include a copy of this form and mail to:
Insurance Consumer Services Section
Arizona Department of Insurance and Financial Institutions
100 N. 15th Ave. Ste. 261
Phoenix, AZ 85007-2630
or EMAIL supporting document along with a copy of this form to insurance.consumers@difi.az.gov
The Arizona Department of Insurance and Financial Institutions provides equal access to communications for people with disabilities. Individuals requiring accommodation with a disability should call the Department`s ADA Coordinator at 602-364-3100.