California Code of Regulations
Title 10 - Investment
Chapter 5 - Insurance Commissioner
Subchapter 3 - Insurers
Article 9.7 - Workers' Compensation Insurance Procedural Requirements and Standards Applicable to Employers, Insurers, and Rating Organizations in the Initiation of and Response to Requests for Review, Requests for Policyholder Information, and Requests for Reconsideration Provided in Insurance Code Sections 11737(f), 11752.6(c), 11753.1(a) and 11753.1(b), and, Rules of Practice and Procedure for Appeals to the Insurance Commissioner Pursuant to Insurance Code Sections 11737(f), 11752.6(c), 11753.1(a), 11753.1(b) and 11753.1
Section 2509.78 - Forms-Declaration of Service by Mail

The following form may be used by a party when serving other parties.

DECLARATION OF SERVICE BY MAIL

In the Matter of

_________________________

Appellant

vs.

_________________________

Respondent

(Insurer or Rating Organization)

I am over the age of 18 years and not a party to this case. On the __________ day of__________, in the year____________________, at _________________________ (city), _________________________(state), I sealed into an envelope and deposited in the United States mail, postage thereon fully prepaid, true copies of the following documents in the above-entitled matter. The original or a true copy of each document served is attached hereto. Said copies were addressed as follows:

_________________________Certified/Registered Mail

Number (if applicable)

I declare under penalty of perjury that the foregoing is true and correct. Executed on ____________________ (month, day), ____________________(year) at _________________________ (city), _________________________(state).

_________________________

(print name)

Declarant

1. New section filed 2-22-99 as an emergency; operative 2-22-99 (Register 99, No. 9). A Certificate of Compliance must be transmitted to OAL by 6-18-99 or emergency language will be repealed by operation of law on the following day.
2. New section refiled 6-18-99 as an emergency; operative 6-18-99 (Register 99, No. 25). A Certificate of Compliance must be transmitted to OAL by 10-18-99 or emergency language will be repealed by operation of law on the following day.
3. New section refiled 10-18-99 as an emergency; operative 10-19-99 (Register 99, No. 43). A Certificate of Compliance must be transmitted to OAL by 2-16-2000 or emergency language will be repealed by operation of law on the following day.
4. Repealed by operation of Government Code section 11346.1(g) (Register 2000, No. 6).
5. New section filed 2-10-2000; operative 3-11-2000 (Register 2000, No. 6).
6. Change without regulatory effect amending NOTE filed 6-3-2003 pursuant to section 100, title 1, California Code of Regulations (Register 2003, No. 23).

Note: Authority cited: Section 11400.20, Government Code; and Section 11753.1, Insurance Code. Reference: Section 11415.10, Government Code; and Sections 11734, 11737(f), 11750, 11752.6(c) and (h), 11753.1(a) and 11753.1(b), Insurance Code.