Regulation 123 Filing Information For Group Insurance Certificates Deemed To Have Been Delivered In New York

Please Specify The Jurisdiction Where The Master Policy Was Lawfully Issued:

Please Identify The Type Of Group To Which The Master Policy Was Delivered:

Different Industry Multiple Employer Trust (4235(c)(1)(D)) Association or Association Trust(4235(c)(1)(K)) Financial Institution (4235(c)(1)(L) Non-Recognized Group (not defined in 4235(c)(1) or 4237(a)(3))