JOHN W. OXENDINE COMMISSIONER OF INSURANCE SAFETY FIRE COMMISSIONER INDUSTRIAL LOAN COMMISSIONER COMPTROLLER GENERAL SEVENTH FLOOR, WEST TOWER FLOYD BUILDING 2 MARTIN LUTHER KING JR. DR. ATLANTA, GA 30334 (404) 656-2056 TDD#(404) 656-4031 Rev No: 11/02 Form No: GID-54 (Ind) 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 NAME _____________________________________ an individual, ADDRESS________________________________________________________________ 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 stipulating and agreeing that such service shall be taken and held in all Courts to be valid and binding upon this partnership. 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. __________________________ Applicant’s Signature _______________ Date Sworn to and subscribed before me this ________ day of _______________________, __________. (NOTARY SEAL) __________________________________ Notary Public My Commission Expires______________ 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