, a duly authorized officer of
, [Name of Insurer] do hereby certify that I am knowledgeable as to
the laws, regulations and circular letters applicable to the type of
insurance coverage and policy form(s) that is (are) the subject of this
filing; that to the best of my knowledge and belief said policy form(s)
is (are) in compliance with the laws, regulations and circular letters
provided in the applicable product outline(s) and product checklist(s).
I further certify that to the best of my knowledge and belief that
the attached filing is in compliance with the product outline (except
if noted below) identified as
and that the information provided in the product checklist(s) attached
to and made part of the submission is complete and accurate.
The policy form differs from the product outline in the following provisions
or contains the following provisions or features not addressed in the
product outline: "list as appropriate". The submission should
include an explanation of such provisions or features.
I further hereby certify that the information set forth in the Accident
and Health Insurance Standard Transmittal Form as submitted with, and
made part of this filing, is true to the best of my knowledge and belief.
I understand that the Department of Financial Services will rely on this certification,
and should it be determined that this certification is materially false
or incorrect, appropriate corrective and disciplinary action, as authorized
by law, will be taken by the Department of Financial Services against the company
and the officer completing this certification.