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Signed and sealed this day of , 20 - <br />WITNESS: <br />(CORPORATE SEAL) <br />WITNESS: <br />Secretary <br />(Name of Corporation) <br />Secretary <br />By: <br />(Signature and Title) <br />(Type Name and Title signed above) <br />(Name of Corporation) <br />By: <br />(Type Name and Title signed above) <br />IN THE PRESENCE OF; INSURANCE COMPANY: <br />*Agent and Attorney -in -Fact <br />Address: <br />(Street) <br />(City /State /Zip Code) <br />Telephone No.. ( ) <br />* (Power of Attorney must be attached) <br />00612-2 <br />