Prior Approval With Certification Filing Information

Note: In order for a submission to be accepted for review under the prior approval with certification process, each of the following items must be completed and all required information and supporting documentation must be submitted with the filing, in addition to the standard transmittal form.
1. A Policy Form Compliance Certification signed by a company officer is attached. Please identify certification type:

(a) Policy Form Compliance Certification based upon checklist (a completed checklist for the product must be attached) - Complete Checklist Certification
(b) Policy Form Compliance Certification based upon a template - Complete Template Certification
(c) Policy Form Compliance Certification based upon a policy form approved for this company within three years of the date of this submission - Complete Previously Approved Form Certification

For items (b) and (c) above, please complete the following items:
A blacklined copy of the template or previously approved form that clearly identifies the differences between the template or previously approved form and the new form is attached.
Form Number of the template or previously approved form
File Number of the template or previously approved form
Approval date of the template or previously approved form.

2. Forms And Any Necessary Supporting Rate Material Are Submitted Together
3. All Forms And Any Necessary Supporting Rate Material Are Completely Developed

4. Supporting Rating Information. Please indicate which of the following is applicable.
(a) Premium Rate Certification signed by a company officer is attached - Complete Premium Rates Compliance Certification
(b) No rate filing is necessary because the submission contains only application forms, disclosure statements, and / or advertising, or the submission is an out of state filing pursuant to section 3201(b)(2)
(c) The forms submission has no premium rate implications and a letter or actuarial memorandum is enclosed which states and justifies this as appropriate.

5. An Actuarial Memorandum is not enclosed because item 4(b) or 4(c) above is checked.
An Actuarial Memorandum Is Enclosed. Rates accompanying a form submission must contain an actuarial memorandum describing all significant data, methods and assumptions used and other supporting materials, accompanied by requisite rate manual pages. If rates supporting the form submission are already on file, the memorandum should provide specific rate manual page references, as needed.