Applicant Name NAIC No. FEIN Uniform Consent to Service of Process Original Designation Amended Designation must be submitted directly to states Insurer Name Previous Name if applicable Home Office Address City State Zip NAIC CoCode The entity 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 busine.
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How to fill out the 03 45636377 online
Filling out the 03 45636377 form online is a straightforward process that requires careful attention to detail. This guide will walk you through each section of the form to ensure you complete it accurately.
Follow the steps to successfully fill out the form.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Fill in the Applicant Name at the top of the form, making sure to include any necessary identifiers like the NAIC number and FEIN number.
- Indicate whether you are submitting an Original Designation or an Amended Designation, marking the appropriate checkbox.
- Complete the Insurer Name field, ensuring it matches the official name of the entity.
- If applicable, include the Previous Name of the entity in the designated field.
- Enter the Home Office Address, including city, state, and zip code, with particular attention to accuracy.
- Provide the NAIC CoCode associated with your entity.
- In the consent section, ensure you clearly understand the legal implications before signing. An authorized officer needs to sign and date the document.
- Complete Exhibit A by placing an 'X' next to the names of all the states where the designated agent is appointing for service of process.
- If applicable, complete Exhibit B, which lists the entities with full names and addresses where service of process will be forwarded.
- Review the Resolution Authorizing Appointment of Attorney section, ensuring it's signed by the authorized officer and the Secretary.
- After completing all sections, save your changes, and consider downloading, printing, or sharing the completed form as required.
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