Free IA-1 - West Virginia

2009 ANNUAL ATTORNEY-IN-FACT FILING For Insurance Companies
Due date April 1, 2009 ­ 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, 2009 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 ____________________________________ ____________________________________ ____________________________________

______________________________ ______________________________ _____________________________ 3. Signature of New agent consenting to the appointment (if applicable): 4. Signature of person authorized to sign on behalf of the company
and their title: 5. Mail form and $25 check to:

___________________________________

____________________________________
Signature/Title:

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.
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Form: IAIF - Revised 2/09