2008 ANNUAL ATTORNEY-IN-FACT FILING
For Insurance Companies
Due date April 1, 2008 – Filing Fee - $25
The Name of Insurance Company is:
Below you will find the information that is requested for your registered insurance company’s
annual filing. Please complete and return to our office along with the twenty-five dollar ($25)
attorney-in-fact fee by April 1, 2008 as required the §33-4-12 of the West Virginia Code. The
check should be made payable to “West Virginia Secretary of State.” Please notice the signature
line. If you change the agent for process, we will need a signature or written consent from the
agent being appointed. This is a requirement of §31D-5-502 and §33-4-12 of the West Virginia
Code.
1. Principal Office Address:
2) Registered Agents Name and Address
For Service of Process
______________________________
____________________________________
______________________________
____________________________________
_____________________________
____________________________________
New
3. Signature of
agent consenting
to the appointment (if applicable):
___________________________________
4. Signature of person authorized
to sign on behalf of the company
____________________________________
and their title:
Signature/Title:
5. Mail form and $25 check to:
West Virginia Secretary of State
Business and Licensing Division
1900 Kanawha Blvd. East
Bldg. 1, Suite 157-K
Charleston, WV 25305-0770
Thank you for your attention to this matter. If you have any questions regarding this mailing
please contact our office and speak with a member of our Business and Licensing Division at
304-558-8000.
Form: IAIF - Revised 1/08