FIS 0273 (9 00) Michigan Office of Financial and Insurance Services Division of Insurance-2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the name of the applicant as it appears on the Articles of Incorporation in the designated field.
3. In the next section, specify the authorized representative's name who will act on behalf of the applicant.
4. Fill in the effective date of this appointment, ensuring accuracy for compliance purposes.
5. Each officer must sign and provide their title in the respective signature fields. Ensure that all signatures are dated appropriately.
6. Witness signatures are also required; make sure to have witnesses sign and date where indicated.
7. Review all entries for completeness and accuracy before finalizing your document.

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