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UCAA Form 12

By Tina Martin,2014-05-06 11:01
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UCAA Form 12

Applicant Name _________________________ NAIC No. _________________

     FEIN: _________________

    Uniform Consent to Service of Process

     ______ Original Designation ______ Amended Designation

     (must be submitted directly to states)

    Insurer Name: ______________________________________________________________________________________

Previous Name (if applicable): _________________________________________________________________________

Home Office Address: _______________________________________________________________________________

City, State, Zip: ______________________________________ NAIC CoCode: _________________________________

The entity named above, organized under the laws of __________________________ , for purposes of complying with the laws of

    the State(s) designate hereunder relating to the holding of a certificate of authority or the conduct of an insurance business within said State(s), pursuant to a resolution adopted by its board of directors or other governing body, hereby irrevocably appoints the officers of the State(s) and their successors identified in Exhibit A, or where applicable appoints the required agent so designated in Exhibit A hereunder as its attorney in such State(s) upon whom may be served any notice, process or pleading as required by law as reflected on Exhibit A in any action or proceeding against it in the State(s) so designated; and does hereby consent that any lawful action or proceeding against it may be commenced in any court of competent jurisdiction and proper venue within the State(s) so designated; and agrees that any lawful process against it which is served under this appointment shall be of the same legal force and validity as if served on the entity directly. This appointment shall be binding upon any successor to the above named entity that acquires the entity’s assets or assumes its liabilities by merger, consolidation or otherwise; and shall be binding as long as there is a contract in force or liability of the entity outstanding in the State. The entity hereby waives all claims of error by reason of such service. The entity named above agrees to submit an amended designation form upon a change in any of the information provided on this power of attorney.

    Applicant Officers’ Certification and Attestation

One of the two Officers (listed below) of the Applicant must read the following very carefully and sign:

     1. I acknowledge that I am authorized to execute and am executing this document on behalf of the Applicant.

     2. I hereby certify under penalty of perjury under the laws of the applicable jurisdictions that all of the forgoing is true and

    correct, executed at ___________________.

    _________________________ __________________________________

     Date Signature of President

     __________________________________

     Full Legal Name of President

    __________________________ __________________________________

     Date Signature of Secretary

     __________________________________

     Full Legal Name of Secretary

?2000, 2005-2008 National Association of Insurance Commissioners October 6, 2008

     1 FORM 12

    Uniform Consent to Service of Process

    Exhibit A

    Place an "X" before the names of all the States for which the person executing this form is appointing the designated agent in that State for receipt of service of process:

     __ AL Commissioner of Insurance # and Resident __ MT Commissioner of Insurance #

    Agent*

     __ AK Director of Insurance # __ NE Officer of Company* or Resident Agent*

    (circle one)

     __ AZ Director of Insurance # ^ __ NH Commissioner of Insurance #

     __ AR Resident Agent * __ NV Commissioner of Insurance of Insurance

    Commission # ^

     __ AS Commissioner of Insurance # __ NJ Commissioner of Banking and Insurance #^

     __ CO Commissioner of Insurance # or Resident __ NM Superintendent of Insurance #

    Agent* (circle one) ^

     __ CT Commissioner of Insurance # __ NY Superintendent of Insurance #

     __ DE Commissioner of Insurance # __ NC Commissioner of Insurance

     __ DC Commissioner of Insurance and Securities __ ND Commissioner of Insurance # ^

    Regulation # or Local Agent* (circle one)

     __ FL Chief Financial Officer # ^ __ OH Resident Agent*

     __ GA Commissioner of Insurance and Safety Fire # __ OR Resident Agent*

    and Resident Agent*

     __ GU Commissioner of Insurance # __ OK Commissioner of Insurance #

     __ HI Insurance Commissioner # and Resident Agent* __ PR Commissioner of Insurance #

     __ ID Director of Insurance # ^ __ RI Commissioner of Insurance ^

     __ IL Director or Insurance # __ SC Director of Insurance #

     __ IN Resident Agent* ^ __ SD Director of Insurance # ^

     __ IA Commissioner of Insurance # __ TN Commissioner of Insurance #

     __ KS Commissioner of Insurance ^ __ TX Resident Agent*

     __ KY Secretary of State # __ UT Resident Agent* ^

     __ LA Secretary of State # __ VT Secretary of State #

     __ MD Insurance Commissioner # __ VI Lieutenant Governor/Commissioner#

     __ ME Resident Agent* ^ __ WA Insurance Commissioner #

     __ MI Resident Agent * __ WV Secretary of State # @

     __ MN Commissioner of Commerce # __ WY Commissioner of Insurance #

     __ MS Commissioner of Insurance and Resident __

    Agent* BOTH are required.

    # For the forwarding of Service of Process received by a State Officer complete Exhibit B listing by state the entities (one per state)

    with full name and address where service of process is to be forwarded. Use additional pages as necessary. Exhibit not

    required for New Jersey, and North Carolina. Florida accepts only an individual as the entity and requires an email address. New

    Jersey allows but does not require a foreign insurer to designate a specific forwarding address on Exhibit B. SC will not forward

    to an individual by name; however, it will forward to a position, e.g., Attention: President (or Compliance Officer, etc.).

    * Attach a completed Exhibit B listing the Resident Agent for the insurer (one per state). Include state name, Resident Agent’s full

    name and street address. Use additional pages as necessary. (DC* requires an agent within a ten mile radius of the District).

^ Initial pleadings only. Kansas requires two signatures.

    @ Form accepted only as part of a Uniform Certificate of Authority application.

    MA will send the required form to the applicant when the approval process reaches that point.

    Exhibit A

    ?2000, 2005-2008 National Association of Insurance Commissioners October 6, 2008 2 FORM 12

    Exhibit B

    Complete for each state indicated in Exhibit A:

    State _________ Name of Entity _____________________________________________________________________

    Phone Number ____________________________________ Fax Number _________________________________

    Email Address ______________________________________________________________________________________

    Mailing Address ____________________________________________________________________________________

    Street Address _____________________________________________________________________________________

    State _________ Name of Entity _____________________________________________________________________

    Phone Number ____________________________________ Fax Number _________________________________

    Email Address ______________________________________________________________________________________

    Mailing Address ____________________________________________________________________________________

    Street Address _____________________________________________________________________________________

    State _________ Name of Entity _____________________________________________________________________

    Phone Number ____________________________________ Fax Number _________________________________

    Email Address ______________________________________________________________________________________

    Mailing Address ____________________________________________________________________________________

    Street Address _____________________________________________________________________________________

    State _________ Name of Entity _____________________________________________________________________

    Phone Number ____________________________________ Fax Number _________________________________

    Email Address ______________________________________________________________________________________

    Mailing Address ____________________________________________________________________________________

    Street Address _____________________________________________________________________________________

    State _________ Name of Entity _____________________________________________________________________

    Phone Number ____________________________________ Fax Number _________________________________

    Email Address ______________________________________________________________________________________

    Mailing Address ____________________________________________________________________________________

    Street Address _____________________________________________________________________________________

    Exhibit B

    ?2000, 2005-2008 National Association of Insurance Commissioners October 6, 2008 3 FORM 12

    Resolution Authorizing Appointment of Attorney

BE IT RESOLVED by the Board of Directors or other governing body of

     _________________________________________________________________________________________________ ,

     (company name)

    this ________ day of _______ , 20 _____ , that the President or Secretary of said entity be and are hereby authorized by the Board of Directors and directed to sign and execute the Uniform Consent to Service of Process to give irrevocable consent that actions may

    be commenced against said entity in the proper court of any jurisdiction in the state(s) of

     _________________________________________________________________________________________________

     _________________________________________________________________________________________________

    in which the action shall arise, or in which plaintiff may reside, by service of process in the state(s) indicated above and irrevocably appoints the officer(s) of the state(s) and their successors in such offices or appoints the agent(s) so designated in the Uniform Consent to Service of Process and stipulate and agree that such service of process shall be taken and held in all courts to be as valid and binding as if due service had been made upon said entity according to the laws of said state.

    CERTIFICATION

    I, ____________________________________________________________________________ , Secretary of

     _________________________________________________________________________________________________ ,

     (company name)

    state that this is a true and accurate copy of the resolution adopted effective the ____ day of _____________ , 20 ___ by the Board of Directors or governing board at a meeting held on the ________________________day of _____________ , 20 ___ or by written

    consent dated _____ day of ____________________, 20 ___.

     _________________________________

     Secretary

?2000, 2005-2008 National Association of Insurance Commissioners October 6, 2008 4 FORM 12

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