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T BOOK 9 r~~e19~ <br />ALAI HORIZATION AND DESIGNATI P FORM y1' <br />`r- <br />. _ - - _ lmm~ .Gm, ]i~~_i I'cil l'na•ram <br />1. AGENT OR BROKER OF RECORD LETTER <br />TO EACH RATING BUREAU WITH RESPECT TO ITS OWN JURISDICTION <br />Please recognize: <br />Childress-Roberts, Incorporated <br />Name of Agem or Broker <br />P. 0. Boy: 1247 Sanford, North Carolina 2'7330 <br />Address o! A,,,w o: 11,Al,7 <br />as our agent or broker o; record and representative in connection with this Program. <br />Thi= letter rescinds am letter preciously filed by us in connection nvith this Program. and reed: - ail amhr:rir: <br />thereunder. <br />This letter does not authorize the agent or broker to inccstieate the schedule makeup of specific _'tlec <br />Notice i= accepted that all authority hereunder mill he ierlninated]bc each rating bureau six mantic: afie; tilt r,:::~ <br />hereon ii insurance is not tcrmen on these iorms by that date. <br />Beare of Co*_-4ssior.ers <br />Lee COt; t; -I Cc_ O~_L2 1-EE County <br />Sams o` ]ndiridua!, Firm or CorPo:a:imi v:d SuLsidiar. F,rms o: Cmt`u: atioro <br />n y1 n Jr.r- <br />2.r10S'C, ir, y`J cayalY. rJ~lwidr<_. <br />7- n ` 19 %C „mourn W Uuidai OC C'..rr:rr <br />Date <br />II. APPOINTMENT OF FILING COMPANY <br />TO EACH RATING BUREAU WITH RESPECT TO ITS OWN JURISDICTION <br />Lee Count-, t=n o i°a; Lee Ccunz-_ Ec~r c= Co- <br />in, hiu-,= co:,ntrice io make .;1: Weer -io:.- 1 cc; nection e.-`i' this }'rtiu a:n all(] .r. <br />ender our c:ih11. izatia:l. <br />Cr_~1G=Etc-?OG6:t5, i~CCr✓OrEtEQ <br />Date 14!- r R.. _ <br />III. DESIGNATION OF SPONSORING RATING BUREAU <br />TO EACH RATING BUREAU WITH RESPECT TO ITS OWN JURISDICTION <br /> <br />: rt' tr• :ir <br />-;l 1 <br />i <br />i err i. <br /> <br />o <br />:!c' n. ; , <br />, t io=::.'d <br />ender ih, Pvi'glam .i' <br />. <br />, <br />. <br />g <br />.t* <br />. <br />the <br />rez;a. <br /> <br />r r. i:: <br />•cd c. <br />.:Div: P <br />rot. a:r allo <br />i2i c, <br />eel. <br />Der, <br />T:•. <br />