Form Fin377 - Service Of Process - Texas Department Of Insurance printable pdf download

Form Fin377 - Service Of Process - Texas Department Of Insurance

FIN377 | 0415

Service of Process Form

THE STATE OF ____________________________

COUNTY OF ______________________________

KNOW ALL MEN BY THESE PRESENT:

THAT THE ________________________________________________________________________________

(Multiple Employer Welfare Arrangement)

of ____________________________________________________ does hereby nominate, constitute and appoint

(domiciliary state)

the Commissioner of Insurance located at _________________________________________________________

in the City of _______________________ Texas ______________ the true and lawful attorney of said company,

for said State of Texas, to acknowledge service of legal process issued by any court of the State of Texas for and on

behalf of said entity, or on whom service of such process may be had, according to the laws of said State of Texas;

hereby waiving all claim or right of error by reason of such acknowledgement of such service of process, whether

intermediate or final. And it is hereby admitted and agreed that such acknowledgement of service of process as

aforesaid shall be taken and held to be as valid and sufficient in that behalf as if served upon the company according

to the laws of said State of Texas, or any other State.

WITNESS out hands and the impress of the seal of said company, this ________day of ______________, 20______.

_____________________________

Trustee or President

(Corporate Seal)

_____________________________

Trustee or Secretary

THE STATE OF _____________________________

COUNTY OF _______________________________

BEFORE ME, _____________________________________________________ on this day personally appeared

both known to me to be the persons whose names are subscribed to the foregoing instrument, and acknowledged

to me that they executed the same for the purposes and considerations therein expressed, in the capacities therein

stated, and as the act and deed of said entity.

IN TESTIMONY WHEREOF, I hereunto sign my name and affix the impress of my official seal this _________ day of

_________________, 20 _______.

________________________________

Notary Public in and for ____________

County, State of __________________

My commission expires ____________

Texas Department of Insurance |

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Form Fin377 - Service Of Process - Texas Department Of Insurance