Form Vsb - Application For Viatical Settlement Broker (Page 3 of 4) in pdf

Form Vsb - Application For Viatical Settlement Broker Page 3

DESIGNATION OF INSURANCE COMMISSIONER AS AGENT FOR SERVICE OF PROCESS

NON-RESIDENT:

IF APPLYING FOR THE FIRST TIME AS NON-RESIDENT, a $10.00 SERVICE OF PROCESS FEE IS

REQUIRED. 36 O.S. §§ 321(A)(3), 4055.3(G)

I designate the Insurance Commissioner of the State of Oklahoma as the person upon who may be served all lawful process in any

action, suit or proceeding instituted by or on behalf of any interested person arising out of my insurance business in the State of

Oklahoma.

This designation shall constitute an agreement that such service of process is of the same legal force and validity as personal service of

process in the State of Oklahoma upon me. This designation further authorizes the Insurance Commissioner of the State of Oklahoma

to forward any such process to me at my last “residence” address as it appears in the Oklahoma Insurance Commissioner’s records. I

understand that a failure to accept any such process shall subject my license to administrative action by the Oklahoma Insurance

Commissioner.

Dated this _______________ day of _________________________________ year of ___________.

__________________________________________

Type or print Name of Applicant, Officer or Partner

__________________________________________

Signature of Applicant, Officer or Partner

NOTARY PUBLIC

I, ______________________________________________________________________, being first duly sworn, state that I have read

the within and foregoing application and that the answers supplied by me therein are true and correct to the best of my knowledge and

belief and further that I will comply with the Insurance Laws of Oklahoma and the Rules of the State Insurance Commissioner in all

my conduct under the license and I will write and receive commissions for the sale of only such insurance for which I am licensed to

sell. I hereby realize that any intentional misstatement of any fact required to be disclosed by the application shall be cause for refusal

or revocation of the license, and constitutes a violation of the Insurance Code of Oklahoma.

State of_____________________________________

______________________________________________

Signature of Applicant

County of ____________________________

________________________________________________

[Seal or Stamp]

Notary Public Signature

My Commission Expires: __________________________

Date_______________

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FORM VSB Rev. 07302013

Form Vsb - Application For Viatical Settlement Broker Page 3