Form 12 Uniform Consent To Service Of Process Page 3
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4Exhibit 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
Revised 11/21/15
2000, 2005-2016 National Association of Insurance Commissioners 3
FORM 12
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