Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 40, subch. II, Appendix, form AA
Filed with the office of the commissioner of insurance,
of the state of Wisconsin
BY
_______________________ _______________________
Name of Affiliate
On Behalf of the Following Insurers
Name Address
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
______________________________________________________________________________________________________
Date: ________, 20___
Name, Title, Address and Telephone Number of Individual to Whom Notices and Correspondence Concerning this Statement Should be Addressed:
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
CONSENT TO JURISDICTION
The, (I), __________________, an affiliate of_______________
(Affiliate) (Insurer)
an insurer authorized to do business in the state of Wisconsin, pursuant to the requirements of ch. 617, Stats., do hereby consent to the jurisdiction of the Commissioner of Insurance and the courts of the state of Wisconsin.
SIGNATURE
_________________________has caused this statement to be
(Name of Affiliate)
duly signed
on its behalf in the city of _________and state of _____________
on the ________ day of ___________, 20____
_______________________________
(Name of Affiliate)
(SEAL)
BY ____________________________
(Name)
________________________________________
(Title)
Attest:
________________________________________
(Signature of Officer)
________________________________________
(Title)
CERTIFICATION
The undersigned deposes and says that he or she has duly executed the attached statement dated ________, 20 ____, for and on behalf of __________________________________ that he or
(Name of Affiliate)
she is the ____________________________ of such company,
(Title of Officer)
and that he or she is authorized to execute and file such instrument. Deponent further says that he or she is familiar with such instrument and the contents thereof, and that the facts therein set forth are true to the best of his or her knowledge and belief.
(Signature)
__________________________________
(Type or print name beneath)
___________________________
Subscribed and sworn to this
__________ day of __________,
Notary Public
My commission expires
_________________________
Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 40, subch. II, Appendix, form AA