Form CDI-076 "Appointment of Agent and Attorney for California" - California

What Is Form CDI-076?

This is a legal form that was released by the California Department of Insurance - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2015;
  • The latest edition provided by the California Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CDI-076 by clicking the link below or browse more documents and templates provided by the California Department of Insurance.

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Download Form CDI-076 "Appointment of Agent and Attorney for California" - California

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STATE OF CALIFORNIA – DEPARTMENT OF INSURANCE
APPOINTMENT OF AGENT AND ATTORNEY FOR CALIFORNIA
CDI-076 (Rev. 12/2015)
KNOW ALL MEN BY THESE PRESENTS:
That __________________________________________________ of ____________________ in the
(Name of Organization or Group)
State of ____________________, desiring to conduct operations as a
_____________________________________________ in the State of California in conformity with
(Advisory Organization; Joint Underwriting and/or Joint Reinsurance Group)
Chapter 9, Part 2, Division 1 of the Insurance Code thereof, has constituted, appointed and designated,
and by these presents does constitute, appoint and designate ______________________________ a
resident of the State of California and having his place of business at ____________________, State of
California, to be its true and lawful agent and attorney, in and for the State of California, upon whom
notices or orders of the Insurance Commissioner or process affecting such organization or group may be
served.
And the said __________________________________________________ hereby stipulates and agrees
(Name of Organization or Group)
that any notices or orders of the Insurance Commissioner or lawful process affecting it which is served on
its said agent and attorney shall be of the same legal force and validity as if served on, and shall give
jurisdiction over the person of, said __________________________________________________ and
(Name of Organization or Group)
and that this appointment and designation, and the powers delegated hereunder, shall terminate only upon
the filing with the Insurance Commissioner of an appointment of another California resident as agent and
attorney, under the provisions of Chapter 9, Part 2, Division 1 of the California Insurance Code, upon
whom notices or orders of the Insurance Commissioner or process affecting said organization or group
may be served; otherwise, this appointment to continue in force irrevocable.
IN WITNESS WHEREOF, the said _____________________________________________ has to these
(Advisory Organization; Joint Underwriting and/or Joint Reinsurance Group)
presents affixed its seal and caused its name to be subscribed and attested to by its
______________________________ and ______________________________ at __________________
(Title of Officer)
(Title of Officer)
State of ____________________ on the _____ day of ____________________, 20_____.
(SEAL)
____________________________________________________
(Name of Advisory Organization; Joint Underwriting and/or Joint Reinsurance Group)
By:
________________________________
Attest: ________________________________
(Name)
(Name)
________________________________
________________________________
(Title of Officer)
(Title of Officer)
STATE OF CALIFORNIA – DEPARTMENT OF INSURANCE
APPOINTMENT OF AGENT AND ATTORNEY FOR CALIFORNIA
CDI-076 (Rev. 12/2015)
KNOW ALL MEN BY THESE PRESENTS:
That __________________________________________________ of ____________________ in the
(Name of Organization or Group)
State of ____________________, desiring to conduct operations as a
_____________________________________________ in the State of California in conformity with
(Advisory Organization; Joint Underwriting and/or Joint Reinsurance Group)
Chapter 9, Part 2, Division 1 of the Insurance Code thereof, has constituted, appointed and designated,
and by these presents does constitute, appoint and designate ______________________________ a
resident of the State of California and having his place of business at ____________________, State of
California, to be its true and lawful agent and attorney, in and for the State of California, upon whom
notices or orders of the Insurance Commissioner or process affecting such organization or group may be
served.
And the said __________________________________________________ hereby stipulates and agrees
(Name of Organization or Group)
that any notices or orders of the Insurance Commissioner or lawful process affecting it which is served on
its said agent and attorney shall be of the same legal force and validity as if served on, and shall give
jurisdiction over the person of, said __________________________________________________ and
(Name of Organization or Group)
and that this appointment and designation, and the powers delegated hereunder, shall terminate only upon
the filing with the Insurance Commissioner of an appointment of another California resident as agent and
attorney, under the provisions of Chapter 9, Part 2, Division 1 of the California Insurance Code, upon
whom notices or orders of the Insurance Commissioner or process affecting said organization or group
may be served; otherwise, this appointment to continue in force irrevocable.
IN WITNESS WHEREOF, the said _____________________________________________ has to these
(Advisory Organization; Joint Underwriting and/or Joint Reinsurance Group)
presents affixed its seal and caused its name to be subscribed and attested to by its
______________________________ and ______________________________ at __________________
(Title of Officer)
(Title of Officer)
State of ____________________ on the _____ day of ____________________, 20_____.
(SEAL)
____________________________________________________
(Name of Advisory Organization; Joint Underwriting and/or Joint Reinsurance Group)
By:
________________________________
Attest: ________________________________
(Name)
(Name)
________________________________
________________________________
(Title of Officer)
(Title of Officer)
STATE OF CALIFORNIA – DEPARTMENT OF INSURANCE
APPOINTMENT OF AGENT AND ATTORNEY FOR CALIFORNIA
CDI-076 (Rev. 12/2015)
To be completed, dated and signed by agent before this is filed with Insurance Department.
AGENT'S ACCEPTANCE OF APPOINTMENT
State of
____________________)
County of
____________________)
I, ______________________________, the appointee named on the obverse side hereof, do hereby
certify under penalty of perjury that I am the individual named therein, that I maintain an office or
residence at the address shown thereon, and that I shall be reasonably available during business hours at
such place for service on me for the appointing entity of papers, notice, proofs of loss, summons, writs or
other process. I further agree that in the event the address or location of my said office or residence is
changed during the existence of this appointment, I will promptly give notice thereon in writing to the
Insurance Commissioner and to the appointing entity.
________________________________
________________________________
Dated
Signature
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