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,

)

)

REQUEST FOR

Applicant (or

)

INTERIM FUNDING

Respondent).

)

)

Petitioner ____________________ hereby request Interim Funding in the above matter.

I

On (date) ____________________ Petitioner became a party (or) participant (whichever is appropriate) in the above hearing.

II

On (date) ____________________ The Commissioner issued a Preliminary Determination of Eligibility to Receive Compensation in this matter.

III

Petitioner ____________________ has substantially contributed to the proceeding to date in that (describe contribution)

IV

A detailed description of the work performed and its relevance to the proceedings is as follows: (cite to the record)

V

A detailed description of services and expenditures of ____________________ in this proceeding are attached and made a part of this petition and is summarized as follows:

VI

WHEREFORE, Petitioner requests that the Commissioner issue an order awarding interim funding found in this Petition and the attached exhibits.

VII

But for the ability to receive interim funding Petitioner continued participation in the proceeding would be jeopardized because:

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).