CIVIL COURT OF THE CITY OF NEW YORK NOTICE OF SERVICE ON AN UNAUTHORIZED INSURER (TO BE SENT BY CERTIFIED MAIL) TO: RE - Index No.: In accordance with 1213 of the Insurance Law of the State of New Yo rk, notice is hereby given to you that I have served the Superintendent of the New Yor k State Insurance Department, as your true and lawful attorney, with a Summons naming you as Defendant in an action. A copy of the Summons referred to is enclosed herewith. Signature Policy Number Print Name CIV-GP-74-A(Revised 1104)-i American LegalNet, Inc. www.USCourtForms.com