Annual Attorney In Fact Filing {IA-1}

Annual Attorney-In-Fact Filing for Insurance Companies for year(enter the CURRENT calendar year) per WV Code 59-1-2a Important Note: This form is a public document. Please DO NOT provide any personal identifiable information on this form such as social security numbers, bank account numbers, credit card numbers, or driver's license numbers. 1.Name of the Organization: 2.Admitted Date: In which State: Zip Code: State: City: Address 1: Address 2:3.Principal Office Address:(if different, please makeappropriate changes)4.Principal Mailing Address:(if different, please makeappropriate changes) Zip Code: State: City: Address 2: Address 1:5.Name and Mailing Address ofperson (Agent) to whom noticeof process may be sent:(if different, please makeappropriate changes) Zip Code: State: City: Address 2: Address 1: Name: *If NEW Agent, furnish new Agent's signature: 6.Business E-mail address where annual mailing notices may be sent: 7.Website address of the business, if any (ex: yourdomainname.com): # of Employees: Phone: Title/Capacity of signer: Date: Signature: 8.REPORT MUST BE SIGNED in the name of the company by a(an): (1) officer of a corporation, (2) notice of process agent, or (3) power of attorney. FILING FEE: Filing deadline 5pm JULY 1 . . . . . $25 MAKE CHECK, MONEY ORDER, OR CASHIER'S CHECK PAYABLE TO: West Virginia Secretary of State SUBMIT COMPLETED FILING TO ONE OF THE BUSINESS CENTERS BELOW: Martinsburg Office Eastern Panhandle Business Center 229 E. Martin Street Martinsburg, WV 25401 Phone: TBA Fax: TBA Hours: Mon. - Fri. 9:00a - 5:00p EST Clarksburg Office North Central WV Business Center 200 West Main Street Clarksburg, WV 26301 Phone: (304) 367-2775 Fax: (304) 627-2243 Hours: Mon. -Fri. 9:00a - 5:00p EST Charleston Office One-Stop Business Center 1615 Washington Street East Charleston, WV 25311 Phone: (304) 558-8000 Fax: (304) 558-8381 Hours: Mon. - Fri. 8:30a - 5:00p ESTRev. 11/2017Form IA-1Issued by the Office of the Secretary of State CHOOSE ONE OF THE FOLLOWING PROCESSING SERVICES: 1 EXPEDITED SERVICE (24-hour, 2-hour and 1-hour; *Requires standard filing fee plus additional expedite fee, see below) West Virginia Secretary of State Business & Licensing Division Tel: (304) 558-8000 Fax: (304) 558-8381 Website: www.wvsos.gov Filing Submission Instructions - Business DivisionSUBMIT THE COMPLETED APPLICATION WITH THE CUSTOMER ORDER REQUEST FORM TO ONE OF THE OFFICES BELOW. CHOOSE EXPEDITED OR STANDARD PROCESSING SERVICE. IF NOT USING THE CUSTOMER ORDER REQUEST FORM AND YOU ARE REQUESTING EXPEDITED SERVICE, YOU MUST INCLUDE THE WORD "EXPEDITE" AND THE LEVEL OF EXPEDITED SERVICE BEING REQUESTED (24-HOUR, 2-HOUR OR 1-HOUR) IN YOUR CORRESPONDENCE. BE SURE TO INCLUDE THE CORRECT ADDITIONAL EXPEDITED FEE. THIS FEE IS IN ADDITION TO THE REGULAR FILING FEE (SEE FEES BELOW).BUSINESS SERVICE CENTERS Standard and Expedited Filings Charleston Office One-Stop Business Center 1615 Washington Street East Charleston, WV 25311 Phone: (304) 558-8000 Fax: (304) 558-8381 Hours: Mon. - Fri. 8:30a - 5:00p EST Clarksburg Office North Central WV Business Center 200 West Main Street Clarksburg, WV 26301 Phone: (304) 367-2775 Fax: (304) 627-2243 Hours: Mon. -Fri. 9:00a - 5:00p EST Martinsburg Office Eastern Panhandle Business Center 229 E. Martin Street Martinsburg, WV 25401 Phone: TBA Fax: TBA Hours: Mon. - Fri. 9:00a - 5:00p ESTIMPORTANT: READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING FORMS. Please follow the instructions included with the application. Failure to include any of the required information on the form may cause the filing to be rejected.All forms may be downloaded from our web site www.wvsos.gov . Rev. 11/2017 *Fee$ 25.00 $250.00 $500.00 Expedite Service 24-Hour 2-Hour 1-HourEXPEDITED SERVICE requests may be submitted by: - E-mail to efilings@wvsos.gov - Fax - Walk in delivery 2 STANDARD PROCESSING (5-10 business days) SUBMIT COMPLETED FILING TO ONE OF THE BUSINESS CENTERS BELOW: INCLUDE PAYMENT: Be sure to enclose the correct filing fee with your filing. If paying by credit card, be sure to include the e-Payment Authorization form with your filing. Your filing will be rejected if the payment is not included or if the e-Payment Authorization form is not included if paying by credit card. Standard filing fees apply.STANDARD PROCESSING requests may be submitted by: - E-mail to CorpFilings@wvsos.gov - Fax - Walk in delivery (drop off service only filed within 5-10 business days) READ CAREFULLY BEFORE SUBMITTING - Expedite service is NOT AVAILABLE for the following filings: West Virginia Secretary of State Business & Licensing Division Tel: (304)558-8000 Fax: (304)558-8381 Website: www.wvsos.gov Customer Order RequestSUBMIT THIS COMPLETED FORM WITH YOUR FILING. Order Processing Requested*: * * * Expedite Processing Requires Additional Fees * * * Standard Processing** 24-HOUR Expedite*** 2-HOUR Expedite 1-HOUR Expedite Name of Entity: Return filing to: (Return Address) Contact Name: Phone: Return Delivery Options: Email or Fax options do not receive a copy via mail; must be ordered separately. Email to: Fax to: Hold for Pick Up UPS: Acct # Other (explain below): (additional $500.00 fee included)(additional $25.00 fee included)(additional $250.00 fee included) FedEx: Acct # Mail to Return Address above Order Description (include items being ordered and fee breakdown): *PLEASE NOTE: Original paperwork is kept by this office. Include a copy of the original filing ifyou want a file stamped copy returned to you at no extra charge. Certified copy requests are an additional $15 per certified copy being requested. Total Amount: Payment Method: Cash (Do Not mail cash) Pre-paid Acct #: Credit Card (Must attach e-Payment Authorization request form including payment information.) Check/Money Order *"Processing" indicates the filing will be completed and registered in the Secretary of State registration database. **Standard Processing applications received by E-MAIL or FAX must include the e-Payment Authorization form with credit card information. ***NOTE: Orders filed in person through any Secretary of State office location requesting the filing be processed will be assessed a 24-HOUR Expedite fee of $25.00 per order.(Avg. processing turnaround 5-10 business days)Rev. 6/2018Attach signed pre-paid slip. >> Tax Department filings including Sole Proprietorships, General Partnerships, and Associations >> Dissolution or Withdrawal of Corporation, Voluntary Association or Business Trust Email to: CorpFilings@wvsos.govEmail to: eFilings@wvsos.gov e-Payment Authorization Credit Card Number: Card Type: Service Type: Fax Mail E-mail Visa Mastercard Discover American Express Payment Information Storage Authorization Year: Entity Name: Name as it appears on the account Billing Address City State Zip Code Telephone Ext.I authorize the Secretary of State to store this payment information for future payment transactions processed by Secretary of State: Authorized Signature X (required) (optional) DateThis document contains confidential financial information and will be properly shredded after payment has been processed by this office. Electronic storage of payment information is only permitted by signed authorization below which may be retracted at any time by written request by the authorized party.Not to Exceed Amount: USD $ Date Month: V Code**3-digit number on back of VISA, MasterCard and Discover cards.4-digit number on front right side of American Express card.NOTICE: For security and verification purposes, all credit card payments must include the 3- or 4-digit CVV2 code (V Code) number located on the credit card. Failure to include this code will result in the rejection of your filing or service request.Rev. 11/2017West Virginia Secretary of State Business & Licensing Division Tel: (304)558-8000 Fax: (304)558-8381 Website: www.wvsos.govUSE BLACK INK ONLY - DO NOT HIGHLIGHT Payment by Card (card holder name and billing address required below) Credit Card Expiration Date: Amount to Charge Card: USD $ Order Information (required) Card Holder Information: Payment Authorization I authorize the Secretary of State to bill an amount not to exceed the following to be ch