SAMPLE ACKNOWLEDGMENT
I certify that I displayed a computer screen illustration for ______________________ that complies with state requirements and for which no hard copy was furnished. The illustration was based on the following personal and policy information:
(or application of non-
guaranteed elements, if
applicable)
_______________________________
AGENT
DATE:_________________________
I acknowledge that I viewed a computer screen illustration based on the information as stated above. No hard copy of the illustration was furnished. I understand that an illustration conforming to the policy as issued will be provided to me no later than at the time the policy is delivered.
_______________________________
APPLICANT
DATE:_________________________
An illustration conforming to the requirements of the model must be prepared and personally delivered by the agent on or before delivery of the policy.
S.D. Admin. R. 20:06:38 app B