State of Domicile: Address:
Telphone Number: Toll Free Number:
Fax Number:

MAIN ADMINISTRATIVE OFFICE (II)

Address:
Telphone Number: Toll Free Number:
Fax Number:

MAIL ADDRESS (III)

Address:
Telphone Number: Toll Free Number:
Fax Number:

The following persons occupy the official positions named below (IV)

President's Name: Office Address:
Secretary's Name: Office Address:

COMPLETED BY:
Telephone Number:
Email Address:

See instructions below for completing official list

INSTRUCTIONS FOR COMPLETING OFFICIAL LIST

(I) STATUTORY HOME OFFICE: As identified with the Certificate of Authority issued by your domicilary state.
(II) MAIN ADMINISTRATIVE OFFICE: Location of the company's main administrative office.
(III) MAIL ADDRESS: Address the company wants mail to go to if other than the Main Administrative Office address; may be a P.O. Box number and the associated zip code.
(IV) Furnish information for only the positions and addresses set out. Do not alter or insert additional positions or addresses. If no one holds a position listed, indicate "NONE". This Department is to be notified promptly of any changes that occur in the positions, addresses and/or telephone numbers during the year.