044-29 Wyo. Code R. §§ 29-11 - Effective Date

These regulations become effective immediately upon filing with the Secretary of State.

CERTIFICATE OF REGISTRATION

This application, made pursuant to Wyoming Insurance Department Regulations, is submitted for the purpose of registering a managing general agent for

_____________________________________________________________________________________________________

Insurer

of_________________________________________________________________________________

Street Address

_____________________________________________________________________________________________________

City, State and Zip Code

1. Name of Managing General Agent _________________________________________________

2. Principal administrative office address ______________________________________________

______________________________________________________________________________________________

3. Managing General Agent's telephone number ________________________________________

4. List names, addresses and titles of all officers if a corporation, partners if a partnership and proprietor if a sole proprietorship.

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

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5. Is it understood that, by filing this registration with the insurance commissioner, the insurer agrees that any violation of the Wyoming Insurance Code, any lawful rule or final order of the commissioner or any final judgment or decree made by any court committed by the managing general agent, while acting within its apparent scope of authority for the insurer shall be deemed to be a violation of said code by the insurer? () Yes () No

I, _________________________________________________________________, on behalf of

Name __________________________________________________________________________________________________,

Insurer

certify that the Managing General Agent designated herein is competent, trustworthy, financially responsible and of good reputation. Attached hereto is a copy of the management contract between the insurer listed above and the Managing General Agent.

__________________________________________________

Signature

__________________________________________________

Title

ACKNOWLEDGMENT:

State of_______________________

County of______________________

The foregoing instrument was acknowledged before me this______day of

__________, 19_. Witness my hand and official seal.

__________________________________________________

Notary Public

My commission expires __________________________________________

Notes

044-29 Wyo. Code R. §§ 29-11