Name

Address

Telephone Number of Petitioner or Attorney

BEFORE THE INSURANCE COMMISSIONER OF THE STATE OF CALIFORNIA

In the Matter of

)

)

Insurance Company,

)

Case No.

)

Applicant (or

)

REQUEST FOR AWARD

Respondent).

)

OF COMPENSATION

)

____________________ hereby requests an award of compensation in the amount of ____________________ for its contribution in this proceeding. In the support of its request, ____________________ alleges:

I

On ____________________ (date) ____________________, (name of petitioner) was found eligible by the Insurance Commissioner to seek an award of compensation in Departmental proceedings.

II

On ____________________ (date), ____________________, (name of petitioner) filed a Notice of Intent to Seek Compensation in this matter.

III

On ____________________ (date) ____________________, the Commissioner issued a preliminary determination finding that

(and)

(if applicable)

On ____________________ (date) ____________________, Petitioner was given an interim award of ____________________ and ____________________ in this proceeding.

IV

A final decision by the Insurance Commissioner was issued in this proceeding on ____________________. This request is timely because it is submitted within 30 days of that day.

V

__________ substantially contributed to the Insurance Commissioner's final decision in that

VI

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

reasonable advocacy fees of:

reasonable witness fees of:

other reasonable expenses of:

VII

The amounts set forth in paragraph VI above are reasonable because

III

On ____________________ (date) ____________________, the Commissioner issued a preliminary determination finding that

VIII

_________________________'s presentation did not materially duplicate the contribution or presentation of any other party to the proceeding in that ____________________.

IX

(If applicable)

Petitioner certifies that it has filed a request for attorney fees under the appropriate statutes in Civil Court (attach a copy).

WHEREFORE, ____________________ respectfully requests an award of compensation in the amount of ____________________ in this proceeding.

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).