Form Fin512 - Agent For Service Of Process - Texas Department Of Insurance
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1FIN512 | 0115
AGENT FOR SERVICE OF PROCESS
The State of ___________________________________
County of
___________________________________
Know All Persons By these Presents:
That the ____________________________________________________________________________________ ,
Reinsurance Intermediary (licensee) does hereby nominate, constitute and appoint
the COMMISSIONER OF INSURANCE, located at 333 Guadalupe, Austin, Texas 78701 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 licensee, 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 or process,
whether intermediate or final. And it is hereby admit- ted 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 licensee according
to law of said State of Texas, or any other State.
The __________________________________________________________________________ hereby commands
the COMMISSIONER OF INSURANCE to forward said legal process to____________________________________
located at _____________________________________ ________________________ Texas, ________________.
ADDRESS
CITY
ZIP
WITNESS our hands this ______ day of _____________________.
_____________________________________________________
AUTHORIZED OFFICER
The State of _____________________________, County of __________________________________________ ,
Before me _________________________________________________________________________ , on this day
(PRINTED NOTARY’S NAME)
personally appeared ____________________________________________________________________ , known
(PRINT NAME OF SIGNING INDIVIDUAL)
to me (or proved to me on the oath of ____________________________________________________________ or
(PRINTED NAME OF WITNESS KNOWN TO NOTARY PUBLIC)
through ________________________________________________________) to be the person whose name is
(DESCRIPTION OF IDENTITY CARD OR OTHER DOCUMENT)
subscribed to the foregoing instrument, and acknowledged to me that (s)he executed the same for the purposes and
consideration therein expressed.
Given under my hand and seal of office this _________ day of ________________________, A.D., __________.
(NOTARY SEAL)
_____________________________________________________________
NOTARY PUBLIC SIGNATURE
Notary Public, State of ___________________________________
Texas Department of Insurance |
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