Wyoming Administrative Code › Agency 044 - Insurance Dept › Sub-Agency 0002 - General Agency, Board or Commission Rules › Chapter 29 - MANAGING GENERAL AGENTS › Section 29-11 - Effective Date

Current through July 13, 2024
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
_____________________________________________________________________________________________________
Insurer
of_________________________________________________________________________________
Street Address
_____________________________________________________________________________________________________
City, State and Zip Code
1. Name of Managing General Agent
				_________________________________________________
2. Principal administrative office address
				______________________________________________
______________________________________________________________________________________________
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.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
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
				  __________________________________________