Texas Department of Insurance



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Texas Department of Insurance

Financial, TPA/Premium Finance, Mail Code 305-TPA/PF

333 Guadalupe • P. O. Box 149104, Austin, Texas 78714-9104

512-305-7521 (TPA) or 512-322-3579 (PF) telephone • 512-322-4380 fax

tdi.state.tx.us

SERVICE OF PROCESS FORM FOR ADMINISTRATORS

(Name of Administrator/Applicant)

an Administrator/Applicant at

(Address)

does hereby nominate, constitute and appoint the COMMISSIONER OF INSURANCE, 333 GUADALUPE, AUSTIN, TEXAS 78701, its true and lawful attorney for the State of Texas, to acknowledge service of legal process issued by any court of the State of Texas according to the laws of Texas, or any other State.

Executive Officer or other comparable responsible person

(Officer, Director, Partner, or Sole Proprietor or Shareholder)

(Printed or typed name)

Date , 20

State of )

)

County of )

Before me, on this day personally appeared _________________________________________, known to me to be the person whose name is subscribed to the foregoing instrument and acknowledged to me that he executed the same for the purposes and consideration therein expressed.

Given under my hand and seal of office this day of , 20 .

Notary Public (Signature)

(Seal)

Printed or Stamped Name

My commission expires

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