Date

To the Director of Insurance

State of Illinois

AUTHORIZATION TO ACCEPT REFERENCE FILINGS OF INLAND MARINE INSURANCE FORMS

The undersigned Company hereby requests that it shall be deemed to have independently submitted as its own filing the forms filed by

(Advisory Organization)

and as changed in its own filing any future change in forms filed by said Advisory Organization and approved for use in the State of Illinois, such change to become effective for this Company upon the same date as it becomes effective for said Advisory Organization's members and subscribers, unless otherwise stipulated by this Company.

This request and direction shall become effective as of the date listed below and shall remain in force until rescinded.

Effective Date

Exceptions, if any:

Company

Official

Title