California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 3 - Annual Statements › Premiums in Course of Collection › Section 2303.22 - Approved Forms

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 Certificate of Assuming Insurer Form AR-1 as published in this section is
					 required under Section
					 2303.4 and
					 2303.5 of this article.
(b) The Designation of Agent for Service of
					 Process and Consent to Jurisdiction Form AR-2 as published in this section is a
					 form acceptable to the Commissioner under the requirements of Sections
					 2303.4 and
					 2303.5 of this article.
(c) The Letter of Credit for Reinsurance Form
					 AR-3 as published in this section is a form acceptable to the commissioner for
					 the purpose of securing ceded reinsurance under Section
					 2303.8 of this article.
(d) Following are Forms AR-1 through AR-3:
FORM AR-1
CERTIFICATE OF ASSUMING INSURER
The undersigned insurer, the Assuming Insurer under a
						reinsurance agreement with one or more insurers domiciled in California, hereby
						certifies that it:
1. Submits to the
					 authority of the Insurance Commissioner of California ("Commissioner") to
					 examine its books and records and agrees to bear the expense of any such
					 examination.
2. Submits with this
					 form a current list of insurers domiciled in California reinsured by Assuming
					 Insurer and undertakes to submit additions to or deletions from the list to
					 Commissioner at least once per calendar quarter, unless the Commissioner
					 approves another reporting interval for additions to or deletions from the
					 list.
Assuming
								Insurer:
___________________________
NAIC #
___________________________
By (Chairman, President or any Vice
								President):
___________________________
Title
___________________________
Date:
___________________________
By (Corporate Secretary, any Assistant Secretary,
								Chief Financial Officer or any Assistant
								Treasurer):
___________________________
Title
___________________________
Date:
___________________________
State/County:
On __________ before me, ______________________________,
						personally appeared ______________________________ and
						______________________________, known to me (or proved to me on the basis of
						satisfactory evidence) to be the persons whose names are subscribed to the
						within instrument and acknowledged to me that they executed the same in their
						authorized capacity, and that by their signatures on the instrument the
						Assuming Insurer, upon behalf of which the persons acted, executed the
						instrument.
Witness my hand and official seal:
Signature ______________________________ Notary
						Public
Form AR-1 (09/04)
DESIGNATION OF AGENT FOR SERVICE OF PROCESS AND
						CONSENT TO JURISDICTION
The undersigned, ______________________________, a
						corporation organized under the laws of ____________________, hereby appoints
						and designates______________________________, having his/her place of business
						at ______________________________ in the City of______________________________,
						California, as its agent for service of process, upon whom may be served any
						notice, summons or process in any action, suit, arbitration or proceeding
						instituted by or on behalf of an insurer domiciled in California or by the
						California Insurance Commissioner ("Commissioner"). If at any time the
						undersigned is without an agent for service of process, or service cannot be
						made upon the appointed agent, service may be made upon the Commissioner, and
						such service shall have the same force and effect as if made upon the
						undersigned. This appointment and designation shall terminate, without notice
						to the appointee, upon filing with the Commissioner a designation form
						appointing another agent.
The undersigned hereby consents to the jurisdiction of
						any court of competent jurisdiction in California for the adjudication of any
						issues arising from a reinsurance agreement with an insurer domiciled in
						California, or arising from its status as an accredited reinsurer or a
						reinsurer with an approved U.S. trust in California. The undersigned agrees to
						comply with all requirements necessary to give such court jurisdiction, and
						will abide by the final decision of such court or appellate court in the event
						of an appeal. However, nothing in this paragraph constitutes a waiver of the
						right of the undersigned 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 arbitrate their disputes if such an obligation is created in an
						underlying agreement.
Name of Corporation ______________________________
By ______________________________ (Officer)
Printed Name and Title of Officer:
______________________________
ACKNOWLEDGMENT OF AGENT
I, ______________________________, the appointee named
						above, hereby certify that I am a licensed attorney in California and the
						individual appointed herein as agent, and that I maintain an office at the
						address stated for me above. I agree to be reasonably available during normal
						business hours at such address for service on me for the appointing company of
						any notice, summons or process. I further agree that in the event the address
						of my office is changed during the existence of this appointment, I will
						promptly give notice thereof in writing to the appointing company and to the
						California Insurance Commissioner.
Signature ______________________________
State of California Bar Number
						_________________________
_______________________________
Submit original to:
California Department
								of Insurance, Corporate Affairs Bureau
45 Fremont Street, San Francisco, CA
								94105
Form AR-2 (09/05)
LETTER OF CREDIT AS SECURITY FOR REINSURANCE
						CEDED
BANK:
ADDRESS:
Letter of Credit No.___________________________
Issue Date:___________________________
To Beneficiary: [Name of Insurer Beneficiary]
We have established this irrevocable, and unconditional
						Letter of Credit in your favor as beneficiary for drawings up to an aggregate
						of U.S. $_______________________, effective immediately. This Letter of Credit
						is issued, presentable and payable at our office at
						______________________________ and expires with our close of business
						on_________________________. Except when the amount is increased, this Letter
						of Credit cannot be modified or revoked without your written consent.
We will promptly honor your sight draft(s) drawn on us,
						indicating our Credit Number_________________________, for all or any part of
						this Letter of Credit, upon presentation at our office at the address given
						above, or such other office as we may advise, on or before the expiration date
						hereof or any automatically extended date. Other than your sight draft, no
						other document need be presented.
This Letter of Credit shall automatically extend without
						amendment for a period of one year from the expiration date, or any future
						expiration date, unless at least sixty (60) days prior to any expiration date
						we notify you by registered or certified mail, return receipt requested, or by
						overnight delivery service, signature upon delivery required, that this Letter
						of Credit shall not be renewed.
Our obligation under this Letter of Credit is
						unconditional and is not dependent upon our ability to perfect a lien, or
						obtain a security interest or any other form of reimbursement.
The term "beneficiary" as used herein includes any
						successor by operation of law of the named beneficiary. If a court of law
						appoints a successor in interest to the named beneficiary, then the term
						"beneficiary" includes and is limited to the court appointed domiciliary
						receiver (including conservator, rehabilitator or liquidator).
This Letter of Credit is subject to and governed by the
						laws of the State of California (excluding the conflict of law provisions), and
						the Uniform Customs and Practice for Documentary Credits, International Chamber
						of Commerce, Publication No. 600, or any successor publication, except where
						that publication is in conflict with California law. Notwithstanding Article 36
						of said publication, if this Letter of Credit expires during an interruption of
						your business or our business, caused by an Act of God, riot, civil commotion,
						insurrection, war, terrorism, or any other cause beyond control or by any
						strike or lockout, we hereby specifically agree to pay as provided herein if
						this Letter of Credit is drawn against within 60 days after the resumption of
						business.
BANK: ______________________________
AUTHORIZED SIGNATURE: _________________________
AR-3 (09/05)