Appendix A.

FORM QR-1
CERTIFICATE OF ASSUMING INSURER

I,

---

,

---

(name of officer)…(title of officer) of

---

, the assuming insurer (name of assuming insurer) under a reinsurance agreement(s) with one or ore insurers domiciled in

---

, hereby certify that (name of state)

---

(name of assuming insurer) (‘‘Assuming Insurer’’): 1. Submits to the jurisdiction of any court of competent jurisdiction in

---

(ceding insurer’s state of domicile)

for the adjudication of any issues arising out of the reinsurance agreement(s), agrees to comply with all requirements necessary to give such court jurisdiction, and will abide by the final decision of such court or any appellate court in the event of an appeal. Nothing in this paragraph constitutes or should be understood to constitute a waiver of Assuming Insurer’s rights to commence an action in any court of competent jurisdiction in the United States, to remove an action to a United States District Court, or to seek a transfer of a case to another court as permitted by the laws of the United States or of any state in the United States. This paragraph is not intended to conflict with or override the obligation of the parties to the reinsurance agreement(s) to arbitrate their disputes if such an obligation is created in the agreement(s). 2. Designates

---

as its lawful (name of lawful agent)

agent upon whom may be served any lawful process in any action, suit or proceeding arising out of the reinsurance agreement(s) instituted by or on behalf of the ceding insurer. 3. Submits to the authority of the Insurance Commissioner of the Commonwealth of Pennsylvania to examine its books and records and agrees to bear the expense of any such examination.

Cross References

This appendix cited in 31 Pa. Code § 161.5 (relating to determination of reinsurer qualification).