Accident and Health Insurance Policy Form Compliance Certification Based Upon Template or Previously Approved Policy Form
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.



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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