Wisconsin Legislature: Ins 40.21 Text

Date: ________, 20___

Name, Title, Address and Telephone Number of Individual to Whom Notices and Correspondence Concerning this Statement Should be Addressed:

___________________________________________________

CONSENT TO JURISDICTION

The, (I), __________________, an affiliate of_______________

(Affiliate) (Insurer)

an insurer authorized to do business in the state of Wisconsin, pursuant to the requirements of ch. 617, Stats., do hereby consent to the jurisdiction of the Commissioner of Insurance and the courts of the state of Wisconsin.

SIGNATURE

_________________________has caused this statement to be

(Name of Affiliate)

duly signed

on its behalf in the city of _________and state of _____________

on the ________ day of ___________, 20____

_______________________________

(Name of Affiliate)

(SEAL)

BY ____________________________

(Name)

________________________________________

(Title)

Attest:

________________________________________

(Signature of Officer)

________________________________________

(Title)

CERTIFICATION

The undersigned deposes and says that he or she has duly executed the attached statement dated ________, 20 ____ , for and on behalf of __________________________________ that he or

(Name of Affiliate)

she is the ____________________________ of such company,

(Title of Officer)

and that he or she is authorized to execute and file such instrument. Deponent further says that he or she is familiar with such instrument and the contents thereof, and that the facts therein set forth are true to the best of his or her knowledge and belief.

(Signature) __________________________________

(Type or print name beneath)___________________________

Subscribed and sworn to this

__________ day of __________,

Notary Public

My commission expires _________________________