California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 9.7 - Workers' Compensation Insurance Procedural Requirements and Standards Applicable to Employers, Insurers, and Rating Organizations in the Initiation of and Response to Requests for Review, Requests for Policyholder Information, and Requests for Reconsideration Provided in Insurance Code Sections 11737(f), 11752.6(c), 11753.1(a) and 11753.1(b), and, Rules of Practice and Procedure for Appeals to the Insurance Commissioner Pursuant to Insurance Code Sections 11737(f), 11752.6(c), 11753.1(a), 11753.1(b) and 11753.1 › Section 2509.78 - Forms-Declaration of Service by Mail

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The following form may be used by a party when serving
					 other parties.
DECLARATION OF SERVICE BY MAIL
In the Matter of
_________________________
Appellant
vs.
_________________________
Respondent
(Insurer or Rating Organization)
I am over the age of 18 years and not a party to this case.
					 On the __________ day of__________, in the year____________________, at
					 _________________________ (city), _________________________(state), I sealed
					 into an envelope and deposited in the United States mail, postage thereon fully
					 prepaid, true copies of the following documents in the above-entitled matter.
					 The original or a true copy of each document served is attached hereto. Said
					 copies were addressed as follows:
_________________________Certified/Registered Mail
Number (if applicable)
I declare under penalty of perjury that the foregoing is
					 true and correct. Executed on ____________________ (month, day),
					 ____________________(year) at _________________________ (city),
					 _________________________(state).
_________________________
(print name)
Declarant
1. New
					 section filed 2-22-99 as an emergency; operative 2-22-99 (Register 99, No. 9).
					 A Certificate of Compliance must be transmitted to OAL by 6-18-99 or emergency
					 language will be repealed by operation of law on the following
					 day.
2. New section refiled 6-18-99 as an emergency; operative
					 6-18-99 (Register 99, No. 25). A Certificate of Compliance must be transmitted
					 to OAL by 10-18-99 or emergency language will be repealed by operation of law
					 on the following day.
3. New section refiled 10-18-99 as an
					 emergency; operative 10-19-99 (Register 99, No. 43). A Certificate of
					 Compliance must be transmitted to OAL by 2-16-2000 or emergency language will
					 be repealed by operation of law on the following day.
4. Repealed by
					 operation of Government Code section
					 11346.1(g)
					 (Register 2000, No. 6).
5. New section filed 2-10-2000; operative
					 3-11-2000 (Register 2000, No. 6).
6. Change without regulatory
					 effect amending NOTE filed 6-3-2003 pursuant to section
					 100, title 1, California Code of
					 Regulations (Register 2003, No. 23).
Note: Authority cited: Section
						11400.20,
						Government Code; and Section
						11753.1,
						Insurance Code. Reference: Section
						11415.10,
						Government Code; and Sections
						11734,
						11737(f),
						11750,
						11752.6(c) and
						(h),
						11753.1(a)
						and
						11753.1(b),
						Insurance Code.