Form 12 Uniform Consent To Service Of Process Page 2
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4Uniform 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
___ MO
Director of Insurance #
Agent*
___
AK
Director of Insurance #
___ MT
Commissioner of Securities and Insurance #
___
AZ
Director of Insurance # ^
___ NE
Officer of Company* or Resident Agent*
(circle one)
___
AR
Resident Agent *
___ NH
Commissioner of Insurance #
___
AS
Commissioner of Insurance #
___ NV
Commissioner of Insurance Commission # ^
___
CO
Commissioner of Insurance # or Resident
___ NJ
Commissioner of Banking and Insurance #^
Agent*
___
CT
Commissioner of Insurance #
___ NM
Superintendent of Insurance #
___
DE
Commissioner of Insurance #
___ NY
Superintendent of Financial Services #
___
DC
Commissioner of Insurance and Securities
___ NC
Commissioner of Insurance
Regulation # or Local Agent* (circle one)
___
FL
Chief Financial Officer # ^
___ ND
Commissioner of Insurance # ^
___
GA
Commissioner of Insurance and Safety Fire #
___ OH
Resident Agent*
and Resident Agent*
___
GU
Commissioner of Insurance #
___ OR
Resident Agent*
___
HI
Insurance Commissioner # and Resident Agent*
___ OK
Commissioner of Insurance #
___
ID
Director of Insurance # ^
___ PR
Commissioner of Insurance #
___
IL
Director of Insurance #
___ RI
Superintendent of Insurance ^
___
IN
Resident Agent* ^
___ SC
Director of Insurance #
___
IA
Commissioner of Insurance #
___ SD
Director of Insurance # ^
___
KS
Commissioner of Insurance ^
___ TN
Commissioner of Insurance #
___
KY
Secretary of State #
___ TX
Resident Agent*
___
LA
Secretary of State #
___ UT
Resident Agent* ^
___
MD
Insurance Commissioner #
___ VT
Secretary of State # or Resident Agent*
___
ME
Resident Agent* ^
___ VI
Lieutenant Governor/Commissioner#
___
MI
Resident Agent *
___ WA
Insurance Commissioner #
___
MN
Commissioner of Commerce ~
___ WV
Secretary of State # @
___
MS
Commissioner of Insurance and Resident
___ WY
Commissioner of Insurance #
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.
Colorado will forward Service of Process to the Secretary of the Applicant Company and requires a resident agent for
foreign entities. 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.). Washington requires an email address on Exhibit B.
*
Attach a completed Exhibit B listing the Resident Agent for the Applicant Company (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.
@ Form accepted only as part of a Uniform Certificate of Authority application.
MA will send the required form to the Applicant Company when the approval process reaches that point.
~
Minnesota does not forward Service of Process. To effectively serve the Commissioner of Commerce, use the process
under Minn. Stat. § 45.028. Applicant Company may complete Exhibit B to provide a Service of Process address that
Commerce may keep on file.
Exhibit A
Revised 11/21/15
2000, 2005-2016 National Association of Insurance Commissioners 2
FORM 12
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