JOHN W. OXENDINE COMMISSIONER OF INSURANCE SAFETY FIRE COMMISSIONER INDUSTRIAL LOAN COMMISSIONER COMPTROLLER GENERAL Rev No: 11/02 SEVENTH FLOOR, WEST TOWER FLOYD BUILDING 2 MARTIN LUTHER KING JR. DR. ATLANTA, GA 30334 (404) 656-2056 TDD#(404) 656-4031 Form No: GID-54 (Corp) OFFICE OF INSURANCE AND SAFETY FIRE COMMISSIONER Consent and Agreement in regarding Service of Process Under the Laws of Georgia State of ________________________ County of ______________________ Know All Men by These Presents, That the _________________________________________, of________________________________________________, corporation duly organized and existing under and by virtue of the Laws of ______________________________________________, does hereby agree and consent that actions may be commenced against it in the proper Court in the State of Georgia, by the service of process upon the Georgia Commissioner of Insurance, hereby stimulating and agreeing that such service shall be taken and held in all Courts to be valid and binding upon this company, association or society, as if personal service had been made upon the President or Secretary, or any other duly authorized and accredited officer thereof. Hereby further agreeing and stipulating that this consent and agreement is and shall remain irrevocable, so long as there is liability, as a third party administrator, within this State, either fixed or contingent Said company does hereby designate _______________________________________ of ________________________________________, __________________________________________, _______________________________________ as the name and address of the person to whom process against it served upon said Commissioner of Insurance to be forwarded. In Witness Whereof, we, the President and Secretary of said company, association or society, respectively have hereunto set our hands and affixed the seal of said corporation on this the _________ day of __________________________, A. D. _________. (SEAL) By _______________________________ President __________________________________ Secretary __________________________________________________________________________________ The foregoing agreement must be accompanied by a duly certified copy of the order or solution of the Board of Directors of the company, association or society, authorizing the President and Secretary to execute the same for and on behalf of the corporation. If you are in individual with a disability and wish to acquire this document in an alternative format, please contact the ADA Coordinator at the Office of Commissioner of Insurance, 2 Martin Luther King Jr. Drive, Atlanta, GA 30334 (404) 656-2056/ (404) 656-4031 American LegalNet, Inc. www.FormsWorkflow.com