I, , _______________ _________________
(name of officer) (title of officer) of _______________ (name of assuming insurer), the assuming insurer under a reinsurance agreement(s) with one or more insurers domiciled in _______________ (name of state), hereby certify that _______________ (name of assuming insurer) ("Assuming Insurer"):
1. Submits to the jurisdiction of any court of competent jurisdiction in ______________ (ceding insurer's state of domicile) for the adjudication of any issues arising out of the reinsurance agreement(s), agrees to comply with all requirements necessary to give such court jurisdiction, and will abide by the final decision of such court or any appellate court in the event of an appeal. Nothing in this paragraph constitutes or should be understood to constitute a waiver of Assuming Insurer's rights to commence an action in any court of competent jurisdiction in the United States, to remove an action to a United States District Court, or to seek a transfer of a case to another court as permitted by the laws of the United States or of any state in the United States. This paragraph is not intended to conflict with or override the obligation of the parties to the reinsurance agreement(s) to arbitrate their disputes if such an obligation is created in the agreement(s).
2. Designates the Insurance Commissioner of ___________________________________ (ceding insurer's state of domicile) as its lawful attorney upon whom may be served any lawful process in any action, suit, or proceeding arising out of the reinsurance agreement(s) instituted by or on behalf of the ceding insurer.
3. Submits to the authority of the Insurance Commissioner of __________________________ (ceding insurer's state of domicile) to examine its books and records and agrees to bear the expense of any such examination.
4. Submits with this form a current list of insurers domiciled in ______________________ (ceding insurer's state of domicile) reinsured by Assuming Insurer and undertakes to submit additions to or deletions from the list to the Insurance Commissioner at least once per calendar quarter.
Dated: _____________________ _______________________
(name of assuming insurer)
BY: _____________________________
(name of officer)
_______________________________
(title of officer)
Effective: January 2012
