Accident and Health Insurance Initial Premium Rates
Compliance Certification
I, , a duly authorized officer of
(insert name of company), do hereby certify that I am knowledgeable as to the laws, regulations and circular letters applicable to the type of insurance coverage and premium rates submitted, and that such rates, actuarial memorandum, supporting rate materials and rate manual pages are in compliance with the applicable laws, regulations and circular letters to the best of my knowledge and belief. I further hereby certify that the information relating to rates 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