Form E128 - Power Of Attorney June 2000 (Page 2 of 2) in pdf

CERTIFIED COPY OF RESOLUTION

At a meeting of the Board of Directors of this ________________________________________ (full and exact

corporate name) held on the _______________ day of ________________________________________,

____________, at its office, a quorum of said board was present, and, on motion, the following resolution was duly

passed by said board:

RESOLVED, that this

(full and exact corporate name)

hereby authorizes its President and Secretary, under its corporate seal, to irrevocably appoint the Director of

Insurance of the State of Arizona, and his or her successor or successors in office, 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 in 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.

And that it hereby further agrees that, as a part 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.

And that it hereby further agrees that when any lawful process against or affecting it is served upon said Director of

Insurance, a copy of said proceedings shall be mailed to:

NAME:

COMPANY:

STREET & NUMBER:

CITY, STATE & ZIP:

TELEPHONE: (

)

And that it hereby further agrees that its President and Secretary are authorized and instructed to execute and deliver

in its name and on its behalf, a Power of Attorney and agreement, in accordance with this resolution.

* * * * * * *

I hereby certify that the above is a correct copy of the resolution

of the Board of Directors of the said

(full and exact corporate name)

Secretary

Note: Provide a certified Corporate Resolution of Authorization for signers other than the President and Secretary.

Form E128 (Rev. 06/00)

Page 2 of 2

Form E128 - Power Of Attorney June 2000 Page 2