23 CAR pt. 125, Appendix C. Issuer Certification Form

APPENDIX C ISSUER CERTIFICATION FORM (relating to Qualified State Long-Term Care Insurance Partnership) In order to provide the Insurance Commissioner with information necessary to provide a certification for policies, this Issuer Certification Form requires information and a certification from issuers of long- term care insurance policies with respect to policy forms that may be covered under the Qualified Partnership of the State. An insurance company may request certification of policies from time to time and, accordingly, may supplement this issuer certification form, e.g., as it introduces new long-term care insurance policy forms for issuance. I. GENERAL INFORMATION A. Name, address and telephone number of issuer: B. Name, address, telephone number, and email address (if available) of an employee of issuer who will be the contact person for information relating to this form: C. Policy form number(s) (or other identifying information, such as certificate series) for policies covered by this Issuer Certification Form (expand the space below as required): Specimen copies of each of the above policy forms, including any riders and endorsements, shall be provided upon request. II. CERTIFICATIONS A. I hereby certify that the policy forms listed above are in compliance with 23 CAR pt. 84 and 23 CAR pt. 125 and all other Arkansas statutes and rules regarding long-term care insurance. B. I hereby certify to the best of my knowledge and belief that all producers who sell, solicit or negotiate long-term care insurance products on {insert issuer name’s} behalf have received the training required for Partnership policies and that they demonstrate an understanding of the policies and their relationship to public and private long-term care coverage. C. I hereby certify that the answers, accompanying documents, and other information set forth herein are, to the best of my knowledge and belief, true, correct, and complete. Date Name and title of officer of the Issuer Signature of officer of the Issuer