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CCIR-1: Appendix VII (01/2000)
Page 2
Canadian Council of Insurance Regulators
Affidavit of Execution
Appendix VII
IN THE MATTER OF THE
(Legislation)
AND THE APPOINTMENT OF A CHIEF AGENT THEREUNDER BY
Name of appointing insurer
TO WIT :
I,
Full name of witness
of the of
Status of municipalityName of municipality
in the of
County, etc., or districtName of county, etc., or district
in
Name of province or state and country
Occupation
MAKE OATH AND SAY THAT :
1. I was personally present and did see the annexed power of attorney duly signed by
and
Full name of signing officer
Full name of signing officer
and did witness the application of the corporate seal of the appointing insurer thereto.
2.I know the said signing officers and they are the
and
Description of office
Description of office
respectively of the said corporation (or « company »).
3.I am the subscribing witness to the said Power of Attorney.
SWORN at the
of
in the
Signature ofwitness
of
this day of 19
NOTE :
To be signed by the party witnessing the signatures
on preceding pageand affidavit of such party to be