Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 6, app A
I __________________________, (name), an officer of____________________(company name), hereby certify that I have authority to bind and obligate the company by filing this (these) form(s). I further certify that, to the best of my information, knowledge and belief:
1. The accompanying form(s) as identified by the attached listing comply(ies) with all applicable provisions of the Wisconsin Statutes and with all applicable administrative rules of the Commissioner of Insurance;
2. The form(s) does (do) not contain any inconsistent, ambiguous, or misleading clauses;
3. The form(s) does (do) not contain specification or conditions that unreasonably or deceptively limit the risk purported to be assumed in the general coverage of the policy form(s);
4. The only variations from a form currently on file with the commissioner of insurance and the only unconventional policy provisions are clearly marked or otherwise indicated pages __________________ of the attached form(s) or in an attachment; and
5. The attached form(s) is (are) in final printed format or typed facsimile and is (are) as will be offered for issuance or delivery in Wisconsin after approval by the Commissioner of Insurance, except for hypothetical data and other appropriate variable material.
6. If this form is a consumer insurance policy, the text of the form(s) meet(s) the minimum reading ease score or, if authorized by the commissioner, the score is lower than the minimum required by s. Ins 6.07(4) (a) 1., Wis. Adm. Code. Product used to determine the Flesch score:____________________.
I understand that the commissioner of insurance will rely on this certification regarding the forms filed, and should it be determined that the policy form(s) does (do) not comply with the applicable laws, regulations, filing requirements and product standards or that this certification is materially false or incorrect, appropriate corrective and disciplinary action, including retroactive disapproval, as authorized by law, may be taken by the commissioner against the company and the officer completing this certification.
(signature)
(title)
(date)
Individual responsible for this filing:
Name: Title:_________________________
Address: ________________
Phone Number:_______________ Date:
Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 6, app A