I hereby make application for insurance to the Old American County Mutual Fire Insurance Company. I hereby appoint the President and Secretary of the Company, or their successors in office, with full power in either to appoint or substitute, to be the undersigned’s lawful proxy and attorney in fact, and said attorney is hereby authorized and empowered to attend any policyholder meeting, or any adjournment or adjournments thereof, and to represent, vote and otherwise act for the undersigned in the same manner and with the same effect as if the undersigned were personally present. This proxy shall continue in force for the full period of the policy and any renewal thereof, unless sooner revoked in writing and shall be irrevocable for the full period permitted by law. I agree to be governed by the provisions of Chapter 912, Texas Insurance Code.

Applicant’s Signature X______________________ Date ___________