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
