Free Notice of Service on an "Unauthorized Insurer" - New York

CIVIL COURT OF THE CITY OF NEW YORK NOTICE OF SERVICE ON AN ''UNAUTHORIZED INSURER'' (TO BE SENT BY CERTIFIED MAIL)

TO:

RE - Index No.:

In accordance with § 1213 of the Insurance Law of the State of New York, notice is hereby given to you that I have served the Superintendent of the New York State Insurance Department, as your true and lawful attorney, with a Summons naming you as Defendant in an action. A copy of the Summons referred to is enclosed herewith.

Signature

Policy Number

Print Name

CIV-GP-74-A(Revised 1104)-i
FREE CIVIL COURT FORM No fee may be charged to fill in this form. Form can be found at: http://www.nycourts.gov/courts/nyc/civil/forms.shtml.