Name

Address

Telephone Number of Petitioner or Attorney

BEFORE THE INSURANCE COMMISSIONER OF THE STATE OF CALIFORNIA

In the Matter of

)

)

Case No.

Insurance Company,

)

)

NOTICE OF INTENT TO

Applicant (or

)

SEEK COMPENSATION

Respondent).

)

)

I

Petitioner ____________________ intends to seek compensation in the above hearing.

II

Petitioner ____________________(describe) represents the interest of the following individual consumers ____________________ and/or consumer group(s) __________.

III

Petitioner ____________________represents no other interest (or) the other interest Petitioner represents is as follows: ____________________ (describe)

IV

Petitioner ____________________ represents a consumer interest not otherwise adequately represented, representation of which is necessary for a fair determination of the proceeding because

V

The issues Petitioner __________ intends to raise and the position of Petitioner on each issue is as follows:

VI

Petitioner ____________________ estimated budget is attached and is summarized as follows:

Wherefore, Petitioner ____________________ requests that the Insurance Commissioner issue a _________________________ determination ____________________ its budget based on the Notice and the attached exhibits.

DATED:

Respectfully Submitted,

____________________

Signature

Note: Authority cited: Sections 1861.10, 12921 and 12926, Insurance Code. Reference: Section 1861.10(a), Insurance Code; and CalFarm Insurance Company, et al. v. George Deukmejian, et al., 48 Cal.3d 805 (1989).

History

1. New section filed 2-1-93; operative 2-1-93 (Register 93, No. 6).