Cal. Code Regs. tit. 10 § 2623.3
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, | ) | |||
| ) | NOTICE OF INTENT TO | |||
| Applicant (or | ) | SEEK COMPENSATION | ||
| Respondent). | ) | |||
| ) | ||||
I
Petitioner ____________________ intends to seek compensation in the above hearing.
II
Petitioner ____________________(describe) represents the interest of the following individual consumers ____________________ and/or consumer group(s) __________.
III
Petitioner ____________________represents no other interest (or) the other interest Petitioner represents is as follows: ____________________ (describe)
___________________________
IV
___________________________
Petitioner
____________________
represents a consumer interest not otherwise adequately represented, representation of which is necessary for a fair determination of the proceeding because
___________________________
___________________________
V
The issues Petitioner __________ intends to raise and the position of Petitioner on each issue is as follows:
___________________________
___________________________
___________________________
VI
___________________________
Petitioner
____________________
estimated budget is attached and is summarized as follows:
___________________________
___________________________
Wherefore, Petitioner ____________________ requests that the Insurance Commissioner issue a _________________________ determination ____________________ its budget based on the Notice and the attached exhibits.
DATED:
Respectfully Submitted,
____________________
Signature
Cal. Code Regs. Tit. 10, § 2623.3
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).