Proxy Acknowledgment of Receipt of Policy and Proxy form for MoDocs physician members. ACKNOWLEDGMENT OF RECEIPT OF POLICYBy signing below, I hereby acknowledge receipt of the Assessment Plan Professional Liability Insurance Policy with Missouri Doctors Mutual Insurance Company.PROXYBy my signature below, I hereby, as of the date provided below, constitute and appoint the then current President or Secretary/Treasurer of Missouri Doctors Mutual Insurance Company (hereinafter MoDocs), as my proxy with full power of substitution to represent the undersigned by casting by proxy the vote to which the undersigned is entitled at all general and special meetings of the members of MoDocs to be held between the date provided below and the date thirty-six (36) months thereafter, at which time this proxy shall expire, unless extended by the undersigned in writing, whenever the undersigned is not personally present at such meeting(s), or at any adjournment thereof, as if the undersigned were personally present. The undersigned hereby ratifies and confirms all that may be done by virtue hereof. This proxy may be revoked by the undersigned by initialing in the space indicated immediately following this sentence and delivering same to the Secretary of MoDocs or as provided by law by the undersigned, but in the absence of such revocation, it shall remain valid during the time herein specified. Failure to use this proxy shall not render it void.Revocation of ProxyPrinted Name(Required)Email Address(Required) Dated(Required) MM slash DD slash YYYY Signature(Required)
