California Code of Regulations
Title 10 - Investment
Chapter 5 - Insurance Commissioner
Subchapter 3 - Insurers
Article 3 - Annual Statements
Premiums in Course of Collection
Section 2303.22 - Approved Forms

1. Submits to the authority of the Insurance Commissioner of California ("Commissioner") to examine its books and records and agrees to bear the expense of any such examination.

2. Submits with this form a current list of insurers domiciled in California reinsured by Assuming Insurer and undertakes to submit additions to or deletions from the list to Commissioner at least once per calendar quarter, unless the Commissioner approves another reporting interval for additions to or deletions from the list.

State/County:

On __________ before me, ______________________________, personally appeared ______________________________ and ______________________________, known to me (or proved to me on the basis of satisfactory evidence) to be the persons whose names are subscribed to the within instrument and acknowledged to me that they executed the same in their authorized capacity, and that by their signatures on the instrument the Assuming Insurer, upon behalf of which the persons acted, executed the instrument.

Witness my hand and official seal:

Signature ______________________________ Notary Public

Form AR-1 (09/04)

DESIGNATION OF AGENT FOR SERVICE OF PROCESS AND CONSENT TO JURISDICTION

The undersigned, ______________________________, a corporation organized under the laws of ____________________, hereby appoints and designates______________________________, having his/her place of business at ______________________________ in the City of______________________________, California, as its agent for service of process, upon whom may be served any notice, summons or process in any action, suit, arbitration or proceeding instituted by or on behalf of an insurer domiciled in California or by the California Insurance Commissioner ("Commissioner"). If at any time the undersigned is without an agent for service of process, or service cannot be made upon the appointed agent, service may be made upon the Commissioner, and such service shall have the same force and effect as if made upon the undersigned. This appointment and designation shall terminate, without notice to the appointee, upon filing with the Commissioner a designation form appointing another agent.

The undersigned hereby consents to the jurisdiction of any court of competent jurisdiction in California for the adjudication of any issues arising from a reinsurance agreement with an insurer domiciled in California, or arising from its status as an accredited reinsurer or a reinsurer with an approved U.S. trust in California. The undersigned agrees to comply with all requirements necessary to give such court jurisdiction, and will abide by the final decision of such court or appellate court in the event of an appeal. However, nothing in this paragraph constitutes a waiver of the right of the undersigned 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 arbitrate their disputes if such an obligation is created in an underlying agreement.

Name of Corporation ______________________________

By ______________________________ (Officer)

Printed Name and Title of Officer:

______________________________

ACKNOWLEDGMENT OF AGENT

I, ______________________________, the appointee named above, hereby certify that I am a licensed attorney in California and the individual appointed herein as agent, and that I maintain an office at the address stated for me above. I agree to be reasonably available during normal business hours at such address for service on me for the appointing company of any notice, summons or process. I further agree that in the event the address of my office is changed during the existence of this appointment, I will promptly give notice thereof in writing to the appointing company and to the California Insurance Commissioner.

Signature ______________________________

State of California Bar Number _________________________

_______________________________

LETTER OF CREDIT AS SECURITY FOR REINSURANCE CEDED

BANK:

ADDRESS:

To Beneficiary: [Name of Insurer Beneficiary]

We have established this irrevocable, and unconditional Letter of Credit in your favor as beneficiary for drawings up to an aggregate of U.S. $_______________________, effective immediately. This Letter of Credit is issued, presentable and payable at our office at ______________________________ and expires with our close of business on_________________________. Except when the amount is increased, this Letter of Credit cannot be modified or revoked without your written consent.

We will promptly honor your sight draft(s) drawn on us, indicating our Credit Number_________________________, for all or any part of this Letter of Credit, upon presentation at our office at the address given above, or such other office as we may advise, on or before the expiration date hereof or any automatically extended date. Other than your sight draft, no other document need be presented.

This Letter of Credit shall automatically extend without amendment for a period of one year from the expiration date, or any future expiration date, unless at least sixty (60) days prior to any expiration date we notify you by registered or certified mail, return receipt requested, or by overnight delivery service, signature upon delivery required, that this Letter of Credit shall not be renewed.

Our obligation under this Letter of Credit is unconditional and is not dependent upon our ability to perfect a lien, or obtain a security interest or any other form of reimbursement.

The term "beneficiary" as used herein includes any successor by operation of law of the named beneficiary. If a court of law appoints a successor in interest to the named beneficiary, then the term "beneficiary" includes and is limited to the court appointed domiciliary receiver (including conservator, rehabilitator or liquidator).

This Letter of Credit is subject to and governed by the laws of the State of California (excluding the conflict of law provisions), and the Uniform Customs and Practice for Documentary Credits, International Chamber of Commerce, Publication No. 600, or any successor publication, except where that publication is in conflict with California law. Notwithstanding Article 36 of said publication, if this Letter of Credit expires during an interruption of your business or our business, caused by an Act of God, riot, civil commotion, insurrection, war, terrorism, or any other cause beyond control or by any strike or lockout, we hereby specifically agree to pay as provided herein if this Letter of Credit is drawn against within 60 days after the resumption of business.

BANK: ______________________________

AUTHORIZED SIGNATURE: _________________________

AR-3 (09/05)