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Service Of Process Consent And Agreemen GID-54- - Georgia
| Service Of Process Consent And Agreemen Form. This is a Georgia form and can be used in Insurance And Safety Fire Commissioner Statewide . |
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OFFICE OF COMMISSIONER OF INSURANCE COMMISSIONER OF INSURANCE ·INDUSTRIAL LOAN COMMISSIONER·SAFETY FIRE COMMISSIONER·COMPTROLLER GENERAL Ralph T. Hudgens, Commissioner www.oci.ga.gov 2 Martin Luther King Jr., Dr., Suite 604, West Tower, Atlanta, GA 30334 Phone: 404-656-7556 Fax: 770-344-5798 E-mail: TBrewster@oci.ga.gov NON-TRADITIONAL ENTITIES SERVICE OF PROCESS CONSENT AND AGREEMENT GID-054-NT FEB11 (same as GID-054-EN) Under the Laws of Georgia State of County of Know All Men by These Presents, That the of , ,existing under and by virtue of the Laws of , does hereby agree and consent pursuant to O.C.G.A.§ 33-59-3(1) that actions may be commenced against it in the proper Court in the State of Georgia, by the service of process upon the Georgia Commissioner of Insurance, hereby stipulating and agreeing that such service shall be taken and held in all Courts to be valid and binding upon this company, association or society, as if personal service had been made upon the President or Secretary, or any other duly authorized and accredited officer thereof. Hereby further agreeing and stipulating that this consent and agreement is and shall remain irrevocable, so long as there is liability, as a Third Party Administrator, within this State, either fixed or contingent Said entity , of does hereby designate: , as the name and address of the person to who process against it served upon said Commissioner of Insurance to be forwarded. In Witness Whereof, we, the President and Secretary of said entity, respectively hereunto set our hands and affixed the seal of said entity on this the day of , A. D. . By President (SEAL) or: __________________________________ Secretary __________________________________ Duly Authorized and Accredited Officer ____________________________________________________________________________________________ The foregoing agreement must be accompanied by a duly certified copy of the order or solution of the Board of Directors of the company, association or society, authorizing the President and Secretary to execute the same for and on behalf of the entity. This office does not discriminate by race, color, national origin, sex, religion, age or disability in employment, programs or services. Disabled persons needing this document in another format can contact the ADA Coordinator for this office at No. 2 Martin Luther King Jr., Dr., Suite 620, Atlanta, GA 30334 - Phone 404-656-2056. Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com
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