R.C.S.A. § 38a-676 APPENDIX I

STATE OF CONNECTICUT POLICY AND ENDORSEMENT CERTIFICATION FORM AS PER CHAPTER 699a OF THE GENERAL STATUTES (READABLE LANGUAGE) PART A Name of Company or Group _______________________________________ Certification applies to: _________________________ ________________________ (Company) (Group) (If certification is made on behalf of a Group of Companies, indicate names of all companies with Group below). COMPLETE EACH APPLICABLE BOX BELOW OR INDICATE NOT APPLICABLE (N.A.) Form is filed by: Company/Group has the following Policy/Form on file in Connecticut Indicate Program Name (Indicate filer by name: rating organization, advisory organization, company)* Homeowners __________________ _____________________ Dwelling Fire __________________ _____________________ Personal, Inland Marine __________________ _____________________ Personal Auto __________________ _____________________ Motorcycle __________________ _____________________ Recreational Vehicle __________________ _____________________ (*) For each policy or endorsement indicated as filed by the Company, it is required that the (*) Company complete Part B of the Policy and Endorsement Certification Form. The company certifies that the above forms filed by the Company or on its behalf and the forms shown on Part B of the Policy and Endorsement Certification Form, meet the minimum standards of readability required by Chapter 699a of the General Statutes and the letter height requirement of regulation 38a-297-3. The type-face style(s) used for the above forms is (are): ______________________________________________________________________ Signed __________________________ Title __________________________ (Officer of the Company) Date __________________________ STATE OF CONNECTICUT POLICY AND ENDORSEMENT CERTIFICATION FORM AS PER CHAPTER 699a OF THE GENERAL STATUTES (READABLE LANGUAGE) PART B Name of Company or Group ________________________________________________ As certified by an officer of the company on Part A, the policy and the related endorsements listed below comply with the minimum standards of readability required by Chapter 699a of the General Statutes and the letter height requirement of regulation 38a-297-3. Options (Check One) \"Sample\" technique can be used only if policy or endorsement contains more than 10,000 words. A copy of policy or endorsement highlighting word samples tested must be attached. 1. Policy and related forms are scored for the Flesch reading ease test as one unit. Companies using the standard Connecticut Basic Reparations Benefits endorsement which has not yet been simplified may exclude this endorsement in the determination of the combined score if they so indicate. 2. Policy and related endorsements are separately scored for Flesch reading ease test. Policy or Endorsement Form No.