Form Oir-C1-144 - Service Of Process Consent And Agreement - Florida Office Of Insurance Regulation


(Please type or print all information clearly)
Original Designation
Insurer Name Change
Merger / Acquisition
Update Delivery Information
Insurer or Company Name:
Previous Name (If applicable):
Home Office Address:
City, State, Zip
FL Company Code
Telephone #
Know all men by these present, that the insurer or other entity named above is subject to the statutory agent for service of process
provisions of the Florida Insurance Code duly organized and existing under and by virtue of the laws of the state of domicile.
Said entity does hereby agree and consent that actions may be commenced against it in any court having jurisdiction in any county in
the State of Florida, in which a cause of action may arise, or in which the plaintiff may reside, by the service of process upon the Chief
Financial Officer of the State of Florida. Said entity also hereby stipulates and agrees that any and all process so served shall be
taken and held in all Courts to be as valid and binding upon this insurer or other entity as if personal service had been made upon the
President or Secretary, or any other duly authorized and accredited officer thereof.
The undersigned hereby further agrees and stipulates that this agreement is and shall remain irrevocable, so long as there is liability,
under any policy, claim or cause of action within this state, either fixed or contingent. Said insurer or other entity does hereby designate
the following as the name and address of the person to whom all process is to be forwarded when process is served upon said Chief
Financial Officer of the State of Florida on behalf of the above named insurer or entity. In the event of a change in the name of the
insurer or the designation of the person to whom process is to be forwarded, whether it be name, address, and/or phone or
fax numbers, the insurer or company shall immediately file a new agreement form with the Chief Financial Officer of the State
of Florida at the address shown at the bottom of this page.
Designated Person
to receive process:
E-Mail Address:
Mailing Address:
Street Address:
I hereby consent and agree to be the person to whom process served upon
the Chief Financial Officer of the State of Florida for said entity, may be forwarded.
In Witness Whereof, we, the President or Chief Executive Officer and Secretary of said insurer or other entity,
being duly authorized by the Board of Directors or governing body of this entity to execute this document, have
hereunto set our hands and affixed the seal of said insurer or other entity on this the
day of
, A.D.
President or CEO's Signature
President or CEO’s Name (Typed or Printed)
Secretary's Signature
Secretary’s Name (Typed or Printed)
Any signatures other than the President, CEO, or Secretary for the Company must be
Rev 06/2004
validated by the attachment of a resolution of the Board of Directors or Governing body
of said company delegating the authority to sign for the company.
Service of Process Section
200 East Gaines Street • PO Box 6200 • Tallahassee, FL 32314-6200 •(850) 413-4200 • Fax (850) 922-2544


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