Section 19 Certificate of Assuming Insurer

• Library: Insurance Practice 2010 Supp Forms

This form and additional information about it are available at:

http://insurance.mo.gov/industry/forms/375-1793.pdf

STATE OF MISSOURI

DEPARTMENT OF INSURANCE

CERTIFICATE OF ASSUMING INSURER

+-------------------------------------------------------------------------------------------------------------------------------+
                | I, _____________________(NAME OF OFFICER)______________ _____________(TITLE OF OFFICER)_________ |
                | of ________(NAME OF ASSUMING INSURER)_____, the assuming insurer under a |
                | reinsurance agreement(s) with one or more insurers domiciled in Missouri, hereby certify that |
                |

...