POWER OF ATTORNEY – CHIEF AGENT
(pursuant to section 579 of the Insurance Companies Act)

KNOW ALL PERSONS BY THESE PRESENTS that (name of Insurance Company), hereinafter called “the Company”, 

1.	nominates, constitutes and appoints (name of Chief Agent) 

(a)	to act as the chief agent in Canada of the Company for the purposes of the Insurance Companies Act;

(b)	to receive service of process in all suits and proceedings against the Company in any province or territory in Canada in respect of any liabilities incurred by it therein; and

(c)	to receive all notices under the laws of Canada from the Minister of Finance or the Superintendent of Financial Institutions; 

2.	declares that the address of the chief agency is (address of chief agency);

3.	declares that service of process or receipt of notice on or by its Chief Agent shall be legal and binding to all intents and purposes whatsoever; and
 
4.	declares that (names and titles of two senior officers of Company who will sign this Power of Attorney) have the power to execute this Power of Attorney.

WHEREOF (names of two senior officers of Company) have executed this Power of Attorney this _______ day of _________________ , 20_______ .

							COMPANY
				
By:

Name:
							Title:

							By:		
					
Name:
							Title:
CONSENT TO ACT AS CHIEF AGENT

I, the undersigned, (name and address of Chief Agent), declare by these presents that I consent to serve as the chief agent of (name of Company) for the purposes of the Insurance Companies Act.

Signed at ________________ , in the _________________ of ___________________ , this _____ day of _________________ , 20_______ .

								_____________________
	 (signature of chief agent)		
        
AFFIDAVIT RE: SIGNATURE OF CHIEF AGENT

I, the undersigned (name of witness), make oath and say that

1.	I was personally present and did see (name of Chief Agent), the Chief Agent of (name of Company), hereinafter called “the Company”, duly sign the Consent to Act as Chief Agent.

2.	I know of my own knowledge that (name of Chief Agent) by whom the signature of Chief Agent was signed is the chief agent of the Company for the purpose of the Insurance Companies Act.
 
3.	I attest that the signature of the Chief Agent is of the proper handwriting of (name of Chief Agent) and the signature of (name of witness) thereto subscribed as the party witnessing the same is my proper handwriting.

Sworn before me at the
_____________ of ______________ ,	}
in the ________________________ 		}
of __________________ , this ____		}		________________________
day of _______________ , 20 _____ .	}		      (signature of witness)

______________________________
 (signature of Commissioner)

Commissioner of Oaths
In and for _____________________
	        (province or territory)