Form 12 Uniform Consent To Service Of Process
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4Applicant Company Name: _____________________________
NAIC No. _________________________
FEIN:
_________________________
Uniform Consent to Service of Process
______ Original Designation
______ Amended Designation
(must be submitted directly to states)
Applicant Company Name: ________________________________________________________________________
Previous Name (if applicable): ______________________________________________________________________
Home Office Address: ____________________________________________________________________________
City, State, Zip: ____________________________________ NAIC CoCode: ________________________________
The Applicant Company 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 Company Officers’ Certification and Attestation
One of the two Officers (listed below) of the Applicant Company 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 Company.
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
Revised 11/21/15
2000, 2005-2016 National Association of Insurance Commissioners 1
FORM 12
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