23 CAR pt. 25, Appendix A. Form AR-1: Certificate of Assuming Insurer

FORM AR-1 CERTIFICATE OF ASSUMING INSURER I,_______________________________________, ____________________________________ (name of officer) (title of officer) of _______________________________________________________________, the assuming insurer (name of assuming insurer) under a reinsurance agreement with one or more insurers domiciled in ___________________________________________________________________, hereby certify that (name of state) __________________________________________________________________(“Assuming Insurer”): (name of assuming insurer) 1. Submits to the jurisdiction of any court of competent jurisdiction___________________________ (ceding insurer’s state of domicile) for the adjudication of any issues arising out of the reinsurance agreement, agrees to comply with all requirements necessary to give such court jurisdiction, and will abide by the final decision of such court or any appellate court in the event of an appeal. Nothing in this paragraph constitutes or should be understood to constitute a waiver of Assuming Insurer’s rights to commence an action in any court of competent jurisdiction in the United States, to remove an action to a United States District Court, or to seek a transfer of a case to another court as permitted by the laws of the United States or of any state in the United States. This paragraph is not intended to conflict with or override the obligation of the parties to the reinsurance agreement to arbitrate their disputes if such an obligation is created in the agreement. 2. Designates the Insurance Commissioner of______________________________________________ (ceding insurer’s state of domicile) as its lawful attorney upon whom may be served any lawful process in any action, suit or proceeding arising out of the reinsurance agreement instituted by or on behalf of the ceding insurer. 3. Submits to the authority of the Insurance Commissioner of _________________________ to examine (ceding insurer’s state of domicile) its books and records and agrees to bear the expense of any such examination. 4. Submits with this form a current list of insurers domiciled in ________________________________ (ceding insurer’s state of domicile) reinsured by Assuming Insurer and undertakes to submit additions to or deletions from the list to the Insurance Commissioner at least once per calendar quarter. Dated: ___________________________ ___________________________________________ (name of assuming insurer) BY: _______________________________________ (name of officer) ___________________________________________ (title of officer)