Accident and Health Policy Form Compliance Certification Based Upon Checklist

I, , 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.


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Signature of Authorized Officer Date
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Print Name of Authorized Officer Address of Insurer, Article 43 Corporation
or HMO
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Title City,State, Zip Code
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Direct Telephone Number E-Mail Address
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Fax Number