Appointment Form Of Director To Acknowledge Or Receive Service Of Process - State Of Missouri, Department Of Insurance Page 2

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COPY OF RESOLUTION

I, ____________________________________________________________________________________________________ , Secretary of the

________________________________________________________________________________________________________________________

a corporation existing under the laws of ______________________________________________________________________________ , do hereby

certify that the following is a true and correct copy, from corporate records of said corporation, of a resolution duly adopted by the Board of Directors

thereof, at a ______________________________________________________________ meeting of said Board, a quorum thereof present and acting,

on the ___________________________________ day of ________________________ , year _________ , to wit:

“RESOLVED, That the president and secretary of this company are hereby authorized to execute in behalf of said company, under the corporate seal thereof, a

written instrument in accordance with the insurance laws of the State of Missouri appointing and authorizing the Director of the Department of Insurance of the State of

Missouri (by whomsoever such office of Director may be held and exercised under the laws of the State of Missouri), for the purpose mentioned in section 375.906

Revised Statutes of Missouri, 1978, to do any and all the things in behalf of this company specified in said section to be done by said Director, and further consenting

that service of process as therein referred to shall be valid and binding, and be deemed personal service service upon this company so long as it shall have any policies

or liabilities outstanding in the State of Missouri.”

And I do further certify that the said resolution has never been rescinded or reconsidered and still remains in force.

GIVEN AND CERTIFIED, at the principal office of said company in the city of __________________________________________________

State of ______________________________________ with the common seal thereof hereto affixed

by the undersigned, having custody of the same as secretary of said company, this

__________________________ day of ________________ , year ________ .

ATTEST:

_______________________________________________________________________ Secretary.

MO 375-0462 (7-99)