044-29 Wyo. Code R. § 29-11
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
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Insurer
of_________________________________________________________________________________
Street Address
_____________________________________________________________________________________________________
City, State and Zip Code
1. Name of Managing General Agent _________________________________________________
2. Principal administrative office address ______________________________________________
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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 __________________________________________
044-29 Wyo. Code R. § 29-11