Form FIS0234 "Foreign Risk Retention Group Consent to Service" - Michigan

What Is Form FIS0234?

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

Form Details:

  • Released on May 1, 2015;
  • The latest edition provided by the Michigan Department of Insurance and Financial Services;
  • 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 FIS0234 by clicking the link below or browse more documents and templates provided by the Michigan Department of Insurance and Financial Services.

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Download Form FIS0234 "Foreign Risk Retention Group Consent to Service" - Michigan

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FIS 0234 (5/15) Department of Insurance and Financial Services Page 1 of 1
Foreign Risk Retention Group Consent to Service
When submitting this form, attach Board of Directors resolution approving the Consent to Service
Name of Foreign Risk Retention Group
Tax ID Number (FEIN)
a Foreign Risk Retention Group, incorporated and doing business under and by the virtue of the laws of
The State of
The Country of
has applied for registration as a Foreign Risk Retention Group to transact liability insurance in the State of Michigan.
Therefore, in compliance with the provisions of Section 500.1811(f) regarding Risk Retention Groups, of the Michigan Insurance Code of 1956, as
amended, the group does hereby make, constitute and appoint the Director of the Department of Insurance and Financial Services of the State of
Michigan, or deputies designated by the Director, as its true and lawful attorney in the State of Michigan, on whom all process of law may be served,
in any action or proceeding under current or future laws and statutes of Michigan in which the group is a party. Further, the group hereby stipulates
and agrees that any legal process affecting such group, served upon the Director of the Department of Insurance and Financial Services, or
designated deputy, shall have the same effect as if personally served upon the group and shall remain in force as long as any liability shall remain
within the State of Michigan. When process against or affecting the group is served on the Director of the Department of Insurance and Financial
Services, or designated deputy, a copy of such process shall be mailed to:
Name
Address Line 1
Address Line 2
City
State
ZIP Code
IN WITNESS WHEREOF, the group in accordance with a resolution of its Board of Directors duly passed, a certified copy of which is hereto
attached, has caused the same to be subscribed and signed in accordance with the bylaws of the group and the resolution of the Board of Directors
thereof, authorizing the same, at
The City of
in the State of
in the Country of
on the
day of
, A.D. 20
Signature of President
Signature of Secretary
PA 218 of 1956 as amended requires submission of this form by Foreign Risk Retention Groups applying for registration in Michigan.
Failure to complete and submit this form properly could result in denial of your application.
When complete, send with Foreign Risk Retention Group application and a copy of the Board of Directors resolution approving the Consent to Service to:
Department of Insurance and Financial Services
PO Box 30165
Lansing, MI 48909-7665
FIS 0234 (5/15) Department of Insurance and Financial Services Page 1 of 1
Foreign Risk Retention Group Consent to Service
When submitting this form, attach Board of Directors resolution approving the Consent to Service
Name of Foreign Risk Retention Group
Tax ID Number (FEIN)
a Foreign Risk Retention Group, incorporated and doing business under and by the virtue of the laws of
The State of
The Country of
has applied for registration as a Foreign Risk Retention Group to transact liability insurance in the State of Michigan.
Therefore, in compliance with the provisions of Section 500.1811(f) regarding Risk Retention Groups, of the Michigan Insurance Code of 1956, as
amended, the group does hereby make, constitute and appoint the Director of the Department of Insurance and Financial Services of the State of
Michigan, or deputies designated by the Director, as its true and lawful attorney in the State of Michigan, on whom all process of law may be served,
in any action or proceeding under current or future laws and statutes of Michigan in which the group is a party. Further, the group hereby stipulates
and agrees that any legal process affecting such group, served upon the Director of the Department of Insurance and Financial Services, or
designated deputy, shall have the same effect as if personally served upon the group and shall remain in force as long as any liability shall remain
within the State of Michigan. When process against or affecting the group is served on the Director of the Department of Insurance and Financial
Services, or designated deputy, a copy of such process shall be mailed to:
Name
Address Line 1
Address Line 2
City
State
ZIP Code
IN WITNESS WHEREOF, the group in accordance with a resolution of its Board of Directors duly passed, a certified copy of which is hereto
attached, has caused the same to be subscribed and signed in accordance with the bylaws of the group and the resolution of the Board of Directors
thereof, authorizing the same, at
The City of
in the State of
in the Country of
on the
day of
, A.D. 20
Signature of President
Signature of Secretary
PA 218 of 1956 as amended requires submission of this form by Foreign Risk Retention Groups applying for registration in Michigan.
Failure to complete and submit this form properly could result in denial of your application.
When complete, send with Foreign Risk Retention Group application and a copy of the Board of Directors resolution approving the Consent to Service to:
Department of Insurance and Financial Services
PO Box 30165
Lansing, MI 48909-7665