Power Of Attorney {DWC-228}

DWC228 Texas Department of Insurance Division of Workers' Compensation Self-Insurance Regulation · MS 60 7551 Metro Center Drive, Suite 100 · Austin, Texas 78744-1645 (512) 804-4775 · (512) 804-4776 fax · www.tdi.texas.gov POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS: That State of Incorporation Name of Principal ,a corporation, hereby makes, constitutes and appoints Name of Agent its true and lawful attorney-in-fact, in its name, place and stead to execute and deliver to the Texas Department of Insurance, Division of Workers' Compensation any and all surety bonds, original or amended, required by the Texas Department of Insurance, Division of Workers' Compensation in order for the Principal to obtain or retain a certificate of self-insurance under the Texas Workers' Compensation Act. Giving and granting to this attorney-in-fact full power and authority to do and perform every act necessary and proper to be done in the exercise of any of the foregoing powers as fully as the principal might or could do if personally present, with full power of substitution, and hereby ratifying and confirming all that attorney-in-fact shall lawfully do or cause to be done by virtue of this document. This power of attorney shall be deemed valid unless and until Principal notifies the Texas Department of Insurance in writing at the Texas Department of Insurance, Division of Workers' Compensation office in Austin, Travis County, Texas that the authority hereby granted has been revoked or has terminated. Said notice shall be addressed to the Texas Department of Insurance, Division of Workers' Compensation and shall not be effective until actually received. DWC228 Rev. 01/07 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com DWC228 If this power of attorney is revoked or otherwise terminated, it shall not have the effect of terminating, restricting or otherwise modifying in any manner the Principal's obligation under any bond or bonds theretofore executed and delivered to the Texas Department of Insurance, Division of Workers' Compensation by the attorney-in-fact hereby appointed. ACKNOWLEDGEMENT The State of County of Executed this day of , . PRINCIPAL: Name of Corporation BY: Authorized Signature(s) Printed Name/Title ATTEST: BY: Corporate Secretary This acknowledges before me on by of Name Name of Principal , , the a Title of Office State of Incorporation corporation, on behalf of said corporation. (Affix Seal Here) DWC228 Rev. 01/07 American LegalNet, Inc. www.FormsWorkFlow.com 2 of 2