Form E128 - Power Of Attorney June 2000
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1
2Department of Insurance
State of Arizona
Financial Affairs Division
2910 NORTH 44TH STREET, SUITE 210
Phoenix, Arizona 85018-7256
Telephone: (602) 912-8420
Telecopier: (602) 912-8421
P O W E R O F A T T O R N E Y
The
(full and exact corporate name)
of the City of
in the State of
hereby irrevocably appoints the Director of Insurance of the State of Arizona, and his or her successor or successors
in office, to be its true and lawful attorney in and for the State of Arizona, upon whom all lawful process in any action
or legal proceeding against it, in any court of said State, may be served.
It hereby further agrees that any lawful process against it, which is served upon and forwarded by said attorney by
registered mail to the person last so designated by it to receive process, shall be of the same legal force and validity
as if served personally upon it, and shall be deemed sufficient service, and that the appointment and authority of said
attorney shall continue so long as any of its liability remains outstanding in said State, and that its removal from said
State or dissolution shall not take away or impair the right to commence any action or legal proceeding against it, in
the manner herein provided, upon a liability previously incurred.
It is hereby further agreed that, as a part of the conditions of its right and authority to transact business in the State
of Arizona, it will and does accept all the terms, obligations, and provisions of the laws of the State of Arizona, now
or hereafter in force, regulating and concerning
(companies, societies or
associations) of its kind and character.
It hereby further agrees that when any lawful process against or affecting it is served up on said Director of
Insurance, a copy of said proceedings shall be mailed to:
NAME:
COMPANY:
STREET & NUMBER:
CITY, STATE & ZIP:
TELEPHONE: (
)
* * * * * * *
The _________________________________ in accordance with the resolution of its Board of Directors duly
passed on _________________________________ (a certified copy of which is attached hereto and made a part
hereof) has to these presents affixed its corporate seal and caused the same to be subscribed by its President, and
attested
by
its
Secretary,
at
the
City
of
_________________________________
in
the
State
of
_______________________ on this __________ day of ___________________________, ___________.
, President
, Secretary
State of
) S.S.
County of
)
On this ______________ day of _____________, ______, before me, ________________________the
undersigned official, personally appeared _________________________ President, and ____________________
Secretary,
who
acknowledged
themselves
to
be
the
President
and
Secretary
respectively,
of
________________________, a corporation, and that they, as such President and Secretary, respectively, being
authorized to do so, executed the foregoing instrument for the purpose therein contained, by signing the name of the
corpora tion by the President, attested by the Secretary, and affixing the corporate seal thereto.
IN WITNESS WHEREOF I hereunto set my hand and official seal.
Notary Public
Commission expires:
Form E128 (Rev. 06/00)
Page 1 of 2
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