Section 2105.13 - Out-of-State Provider Jurisdiction Agreement| State of California | Department of Insurance |
| Prelicensing/Continuing Education Program | |
| Out-of-State Provider Jurisdiction Agreement | |
| 446-40 (Rev. 02/2001) | |
___________________________
Producer Licensing Bureau--Education Section
320 CAPITOL MALL
SACRAMENTO, CA 95814-4309
Information (916) 492-3064
www.insurance.ca.gov
| INSTRUCTIONS: | DEPARTMENT USE ONLY: | |
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| * This form must be completed by every provider and provider applicant whose head office is located outside of California. | Provider Number ___________________________ | |
| Date Received ___________________________ | |
| Provider Number (if none, mark "pending"): ___________________________ | | Date: ___________________________ | |
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| Provider Name: ___________________________ | | Telephone: ___________________________ |
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| Address: | | |
| ___________________________ |
| Street | City | State | Zip |
On behalf of the above named provider, I stipulate and agree:
(a) That in any action or special proceeding brought against the provider in the State of California, any document or process may be served on the commissioner with the same effect as though served upon the provider, and such service will give jurisdiction over the provider to the same extent as if the provider were a resident of the State of California.(b) That any action or special proceeding brought by the provider against the Insurance Commissioner of the State of California will be brought in the City and County of San Francisco or in the County of Los Angeles.(c) That the provider will appear at the Office of the Insurance Commissioner in the City of San Francisco or in the City of Los Angeles at any time, pursuant to notice of hearing, order to show cause, or subpoena issued by the commissioner, if such document is deposited in the United States mail, certified and postage prepaid, in a cover addressed to the provider at the last address filed by it with the commissioner, such deposit in mail being 31 or more days before the date specified in such document for such appearance, and that in the event of failure so to appear the provider hereby consents to recession or denial of provider certification by the commissioner. PROVIDER DIRECTOR NAME____________________________________________________________(Print or type)
PROVIDER DIRECTOR SIGNATURE: ________________________________________
DATE:______________________________
Cal. Code Regs. Tit. 10, § 2105.13
1. New section filed 8-20-2007; operative 9-19-2007 (Register 2007, No. 34). Note: Authority cited: Section 1812, Insurance Code. Reference: Section 1810.7, Insurance Code.
1. New section filed 8-20-2007; operative 9-19-2007 (Register 2007, No. 34).