| 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) submitted, that any changes to
's [Name of Insurer] approved template language or the language of the
previously approved policy form upon which this submission is based are
highlighted in the attached black-lined copies of the forms submitted
and that all changes to approved language are in compliance with the applicable
law, regulations and circular letters to the best of my knowledge and
belief.
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. |