Cal. Code Regs. tit. 10, § 2105.13
(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:______________________________
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:
* 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:
Provider Name:
Telephone:
Address:
Street
City
State
Zip
On behalf of the above named provider, I stipulate and agree:
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).