Alberta Power of Attorney FormAlberta Power of Attorney FormAlberta Power of Attorney Form
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Canadian Council of Insurance Regulators
Power of Attorney
Appendix VII
(To be completed for each licensing jurisdiction except Quebec, which requires a prescribed form)

KNOW ALL MEN BY THESE PRESENTS THAT
Name of appointing insurer

an insurer organized and existing under the laws of
Country or province or state

and licensed to carry on business in
Jurisdiction

and having its head office in
City, province or state, country

hereby nominates, constitutes and appoints, under the provisions of
Legislation

as its true and lawful attorney and chief agent resident in the above jurisdiction and located at :
Name of chief agent in full

Business address and telephone number

for the purposes of the above legislation.
The said chief agent is hereby expressly authorized to receive service of process in all suits and proceedings against the
said insurer in the above named jurisdiction in respect of any liability incurred by it therein, and also to
receive from

all notices that the law requi