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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