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Service Of Process Consent And Agreemen Form. This is a Georgia form and can be use in Insurance And Safety Fire Commissioner Statewide.
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Tags: Service Of Process Consent And Agreemen, GID-54-, Georgia Statewide, Insurance And Safety Fire Commissioner
OFFICE OF COMMISSIONER OF INSURANCE
COMMISSIONER OF INSURANCE •INDUSTRIAL LOAN COMMISSIONER•SAFETY FIRE COMMISSIONER•COMPTROLLER GENERAL
Ralph T. Hudgens, Commissioner
www.oci.ga.gov
2 Martin Luther King Jr., Dr., Suite 604, West Tower, Atlanta, GA 30334
Phone: 404-656-7556 ◊ Fax: 770-344-5798 ◊ E-mail: TBrewster@oci.ga.gov
SERVICE OF PROCESS CONSENT AND AGREEMENT
NON-TRADITIONAL ENTITIES
GID-054-NT FEB11
(same as GID-054-EN)
Under the Laws of Georgia
State of
County of
Know All Men by These Presents, That the
,
of
,existing under and by virtue of the Laws of
, does hereby agree and consent pursuant to O.C.G.A.§
33-59-3(1) 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 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 entity
,
of
does hereby designate:
,
as the
name and address of the person to who process against it served upon said Commissioner of Insurance to be
forwarded.
In Witness Whereof, we, the President and Secretary of said entity, respectively hereunto set our hands
and affixed the seal of said entity on this the
day of
, A. D.
.
By
President
__________________________________
Secretary
(SEAL)
or:
__________________________________
Duly Authorized and Accredited Officer
____________________________________________________________________________________________
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 entity.
This office does not discriminate by race, color, national origin, sex, religion, age or disability in employment, programs or services. Disabled persons needing this document in
another format can contact the ADA Coordinator for this office at No. 2 Martin Luther King Jr., Dr., Suite 620, Atlanta, GA 30334 - Phone 404-656-2056.
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