Notificación de Persona Contacto

[LOGO] ESTADO LIBRE ASOCIADO DE PUERTO RICO OFICINA DEL COMISIONADO DE SEGUROS 14 de julio de 2015 ### CARTA CIRCULAR NÚM.: CC-2015-1863-AF A TODOS LOS ASEGURADORES DEL PAÍS Y EXTRANJEROS AUTORIZADOS PARA REALIZAR NEGOCIOS DE SEGUROS EN PUERTO RICO ### NOTIFICACION DE PERSONA CONTACTO Estimadas señoras y señores: Como parte del esfuerzo de la Oficina del Comisionado de Seguros para optimizar la comunicación con los regulados y actualizar nuestra base de datos, hemos adoptado un procedimiento para que notifiquen o actualicen la información en torno a la persona contacto para propósitos regulatorios ("Regulatory Compliance/Government Relations Contact"), así como la persona o entidad a cargo de recibir emplazamiento a nombre del asegurador ("Agent for Service of Process"), entre otros. A tales efectos se hace disponible la Forma OCS-AF-2015-004 y la Forma 12, las cuales deberán ser sometidas a nuestra Oficina no más tarde del 31 de julio de 2015 a través de la siguiente dirección de correo electrónico contactnotification@ocs.gobierno.pr. Se advierte que la Forma 12 sólo debe ser completada por los aseguradores extranjeros¹ a través del "Uniform Certificate of Authority Aplication (UCAA)". Se requiere estricto cumplimiento con las disposiciones de esta Carta Circular. Cordialmente, Angela Weyne Roig Comisionada de Seguros Anejos ¹ Asegurador que se constituye con arreglo a las leyes de otro estado o país que no sea Puerto Rico. B5 Calle Tabonuco Suite 216 • PMB 356 • Guaynabo, PR 00968-3029 • Tel: (787) 304-8686 • Fax: (787) 273-6082 www.ocs.gobierno.pr [LOGO] COMMONWEALTH OF PUERTO RICO OFFICE OF THE COMMISSIONER OF INSURANCE Applicant Company Name: _________________________ NAIC No. _________________________ FEIN: _________________________ ### CONTACT NOTIFICATION FORM At least contact 1 and 4 must be completed and notified by the Insurer. Please mark with an "X" the corresponding contact and provide the information requested below: | 1 | | Consumer Complaints Contact | A contact person for the OCI consumer complaint staff to contact for resolution of complaints filed with the state department. | | --- | --- | --- | --- | | 2 | | Regulatory Compliance/Government Relations Contact | A contact person for the OCI to contact on matters related to regulation but unrelated to public complaints filed with the state department.) | | 3 | | Premium Tax Contact | A contact person for the OCI to contact regarding issues of payment of premium tax. | | 4 | | Circulation of Risks | A contact person for the OCI to contact in case of reproduction of a policy contract. | | 5 | | Other | | Contact Name: ________________________________________________________________________ Title: ________________________________________________________________________________ Address: ______________________________________________________________________________ Phone #: _________________________ Fax #: _________________________ E-Mail Address: _________________________ Previous Contact Name (if changed): ____________________________________________________ Signature of Preparer Date of Preparation Typed or Printed Name Title of Preparer Phone Number of Preparer Email Address of Preparer Office of the Commissioner of Insurance of Puerto Rico FORM-OCS-AF-2015-004 Applicant Company Name: _________________________ NAIC No. _________________________ FEIN: _________________________ ### Uniform Consent to Service of Process ☐ Original Designation ☐ Amended Designation (must be submitted directly to states) Applicant Company Name: _________________________ Previous Name (if applicable): _________________________ Home Office Address: _________________________ City, State, Zip: _________________________ NAIC CoCode: _________________________ The Applicant Company named above, organized under the laws of _________________________, for purposes of complying with the laws of the State(s) designate hereunder relating to the holding of a certificate of authority or the conduct of an insurance business within said State(s), pursuant to a resolution adopted by its board of directors or other governing body, hereby irrevocably appoints the officers of the State(s) and their successors identified in Exhibit A, or where applicable appoints the required agent so designated in Exhibit A hereunder as its attorney in such State(s) upon whom may be served any notice, process or pleading as required by law as reflected on Exhibit A in any action or proceeding against it in the State(s) so designated; and does hereby consent that any lawful action or proceeding against it may be commenced in any court of competent jurisdiction and proper venue within the State(s) so designated; and agrees that any lawful process against it which is served under this appointment shall be of the same legal force and validity as if served on the entity directly. This appointment shall be binding upon any successor to the above named entity that acquires the entity's assets or assumes its liabilities by merger, consolidation or otherwise; and shall be binding as long as there is a contract in force or liability of the entity outstanding in the State. The entity hereby waives all claims of error by reason of such service. The entity named above agrees to submit an amended designation form upon a change in any of the information provided on this power of attorney. ### Applicant Company Officers' Certification and Attestation One of the two Officers (listed below) of the Applicant Company must read the following very carefully and sign: 1. I acknowledge that I am authorized to execute and am executing this document on behalf of the Applicant Company. 2. I hereby certify under penalty of perjury under the laws of the applicable jurisdictions that all of the forgoing is true and correct, executed at _________________________. Date Signature of President Full Legal Name of President Date Signature of Secretary Full Legal Name of Secretary ©2000, 2005-2015 National Association of Insurance Commissioners 1 Revised 8/18/14 FORM 12 # Uniform Consent to Service of Process ## Exhibit A Place an "X" before the names of all the States for which the person executing this form is appointing the designated agent in that State for receipt of service of process: | ☐ | AL | Commissioner of Insurance # and Resident Agent* | ☐ | MO | Director of Insurance # | | --- | --- | --- | --- | --- | --- | | ☐ | AK | Director of Insurance # | ☐ | MT | Commissioner of Securities and Insurance # | | ☐ | AZ | Director of Insurance # ^ | ☐ | NE | Officer of Company* or Resident Agent* (circle one) | | ☐ | AR | Resident Agent * | ☐ | NH | Commissioner of Insurance # | | ☐ | AS | Commissioner of Insurance # | ☐ | NV | Commissioner of Insurance Commission # ^ | | ☐ | CO | Commissioner of Insurance # or Resident Agent* | ☐ | NJ | Commissioner of Banking and Insurance #^ | | ☐ | CT | Commissioner of Insurance # | ☐ | NM | Superintendent of Insurance # | | ☐ | DE | Commissioner of Insurance # | ☐ | NY | Superintendent of Financial Services # | | ☐ | DC | Commissioner of Insurance and Securities Regulation # or Local Agent* (circle one) | ☐ | NC | Commissioner of Insurance | | ☐ | FL | Chief Financial Officer # ^ | ☐ | ND | Commissioner of Insurance # ^ | | ☐ | GA | Commissioner of Insurance and Safety Fire # and Resident Agent* | ☐ | OH | Resident Agent* | | ☐ | GU | Commissioner of Insurance # | ☐ | OR | Resident Agent* | | ☐ | HI | Insurance Commissioner # and Resident Agent* | ☐ | OK | Commissioner of Insurance # | | ☐ | ID | Director of Insurance # ^ | ☐ | PR | Commissioner of Insurance # | | ☐ | IL | Director of Insurance # | ☐ | RI | Superintendent of Insurance ^ | | ☐ | IN | Resident Agent* ^ | ☐ | SC | Director of Insurance # | | ☐ | IA | Commissioner of Insurance # | ☐ | SD | Director of Insurance # ^ | | ☐ | KS | Commissioner of Insurance ^ | ☐ | TN | Commissioner of Insurance # | | ☐ | KY | Secretary of State # | ☐ | TX | Resident Agent* | | ☐ | LA | Secretary of State # | ☐ | UT | Resident Agent* ^ | | ☐ | MD | Insurance Commissioner # | ☐ | VT | Secretary of State # or Resident Agent* | | ☐ | ME | Resident Agent* ^ | ☐ | VI | Lieutenant Governor/Commissioner# | | ☐ | MI | Resident Agent * | ☐ | WA | Insurance Commissioner # | | ☐ | MN | Commissioner of Commerce # | ☐ | WV | Secretary of State # @ | | ☐ | MS | Commissioner of Insurance and Resident Agent* BOTH are required. | ☐ | WY | Commissioner of Insurance # | # For the forwarding of Service of Process received by a State Officer complete Exhibit B listing by state the entities (one per state) with full name and address where service of process is to be forwarded. Use additional pages as necessary. Colorado will forward Service of Process to the Secretary of the Applicant Company and requires a resident agent for foreign entities. Exhibit not required for New Jersey, and North Carolina. Florida accepts only an individual as the entity and requires an email address. New Jersey allows but does not require a foreign insurer to designate a specific forwarding address on Exhibit B. SC will not forward to an individual by name; however, it will forward to a position, e.g., Attention: President (or Compliance Officer, etc.). Washington requires an email address on Exhibit B. * Attach a completed Exhibit B listing the Resident Agent for the Applicant Company (one per state). Include state name, Resident Agent's full name and street address. Use additional pages as necessary. (DC* requires an agent within a ten mile radius of the District). ^ Initial pleadings only. @ Form accepted only as part of a Uniform Certificate of Authority application. MA will send the required form to the Applicant Company when the approval process reaches that point. ## Exhibit A ©2000, 2005-2015 National Association of Insurance Commissioners 2 Revised 8/18/14 FORM 12 # Exhibit B Complete for each state indicated in Exhibit A: State: ________________________ Name of Entity: ____________________________________________________ Phone Number: ____________________________________________________ Fax Number: ________________________ Email Address: ____________________________________________________________________________________ Mailing Address: __________________________________________________________________________________ Street Address: ___________________________________________________________________________________ State: ________________________ Name of Entity: ____________________________________________________ Phone Number: ____________________________________________________ Fax Number: ________________________ Email Address: ____________________________________________________________________________________ Mailing Address: __________________________________________________________________________________ Street Address: ___________________________________________________________________________________ State: ________________________ Name of Entity: ____________________________________________________ Phone Number: ____________________________________________________ Fax Number: ________________________ Email Address: ____________________________________________________________________________________ Mailing Address: __________________________________________________________________________________ Street Address: ___________________________________________________________________________________ State: ________________________ Name of Entity: ____________________________________________________ Phone Number: ____________________________________________________ Fax Number: ________________________ Email Address: ____________________________________________________________________________________ Mailing Address: __________________________________________________________________________________ Street Address: ___________________________________________________________________________________ State: ________________________ Name of Entity: ____________________________________________________ Phone Number: ____________________________________________________ Fax Number: ________________________ Email Address: ____________________________________________________________________________________ Mailing Address: __________________________________________________________________________________ Street Address: ___________________________________________________________________________________ # Exhibit B ©2000, 2005-2015 National Association of Insurance Commissioners 3 Revised 8/18/14 FORM 12 # Resolution Authorizing Appointment of Attorney BE IT RESOLVED by the Board of Directors or other governing body of (Applicant Company Name) this ____ day of ____, 20 ____, that the President or Secretary of said entity be and are hereby authorized by the Board of Directors and directed to sign and execute the Uniform Consent to Service of Process to give irrevocable consent that actions may be commenced against said entity in the proper court of any jurisdiction in the state(s) of in which the action shall arise, or in which plaintiff may reside, by service of process in the state(s) indicated above and irrevocably appoints the officer(s) of the state(s) and their successors in such offices or appoints the agent(s) so designated in the Uniform Consent to Service of Process and stipulate and agree that such service of process shall be taken and held in all courts to be as valid and binding as if due service had been made upon said entity according to the laws of said state. CERTIFICATION: I, ____, Secretary of (Applicant Company Name) state that this is a true and accurate copy of the resolution adopted effective the ____ day of ____, 20 ____ by the Board of Directors or governing board at a meeting held on the ____ day of ____, 20 ____ or by written consent dated ____ day of ____, 20 ____. Secretary ©2000, 2005-2015 National Association of Insurance Commissioners 4 Revised 8/18/14 FORM 12