CIVIL COURT OF THE CITY OF NEW YORK County of Index No.: AFFIDAVIT OF COMPLIANCE WITH THE INSURANCE LAW State of New York, County of ss: , being duly sworn, deposes and says: I am over 18 years of age and I am the Claimant in this action. On I complied with 1213 of the Insurance Law of the State of New York in that I 1. served the Superintendent of the State Insurance Department with the original Summons in this matter along with payment of the required fee, and I als o 2. mailed Notice of this action to the Defendant, along with a copy of t he Summons in the matter, by Certified Mail, Return Receipt Requested. Proof of such mailing to the Defendant is documented by: The signed and dated Return Receipt form which is annexed herewith. The original envelope annexed herewith, bearing the notation by the Post al Service that the mail was refused by the Defendant. Signature of Deponent Print Name of Deponent Sworn to before me this day of 20 Notary Public CIV-GP-74-B(Revised 1104)-i American LegalNet, Inc. www.USCourtForms.com