Affidavit for Lost Certificate of Authority



|[pic] |Department of Consumer & Business Services | |

| |Insurance Division — 4 | |

| |P.O. Box 14480, Salem, OR 97309-0405 | |

| |Phone: 503-947-7982, Fax: 503-378-4351 | |

| |350 Winter St. NE, Salem, OR 97301-3883 | |

| |E-mail: dcbs.insmail@state.or.us | |

| |insurance. | |

| |

| |      | |

| (Insurer name) |

|We have conducted a diligent search for our original Oregon Certificate of Authority and we are unable to find it. We understand that this certificate is the |

|property of the State of Oregon Insurance Division and will return the original Oregon Certificate of Authority if we find it. |

| |

| |      | |

| |(Signature of company officer) |

| |      | |

| |(Title) |

| |

|Subscribed and sworn to before me this |      |day of |      |, 20 |      | |

| | | |

| |      | |

| |Notary public in and for the State of | |

| |      | |

| |My commission expires: |      | |

[pic]

440-2361 (12/08/COM)

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Affidavit for Lost

Certificate of Authority

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