_____day of _________, _____.
Notary Public _______________________________
My commission expires _______________________
FORM C
CONSENT TO JURISDICTION STATEMENT
Filed with the office of the commissioner of insurance,
state of Wisconsin
BY
______________________________________
(Name of Affiliate)
On Behalf of the Following Care Management Organizations
Name Address
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
Date:__________,_____.
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) (Care Management Organization)
a care management organization permitted to do business in the state of Wisconsin, pursuant to the requirements of ch. 648, 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 duly signed on
(Name of Affiliate)
its behalf in the city of ____________________ and state of
______________ on the ________day of__________, _____.
________________________
(Name of Affiliate)
(SEAL)
BY_______________________
(Name)
__________________________
(Title)
Attest: _______________________
(Signature of Officer)
_____________________________
(Title)
CERTIFICATION
The undersigned deposes and says that (s)he has duly executed the attached statement dated __________, ______, for and on behalf of_____________________that (s)he is the
(Name of Registrant)
_____________ of such company, and that (s)he is authorized
(Title of Officer)
to execute and file such instrument. Deponent further says that (s)he 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 ___________________
