California Code of Regulations
Title 10 - Investment
Chapter 5 - Insurance Commissioner
Subchapter 4.5 - General Provisions
Article 9 - Forms
Section 2623.6 - Verification (for Corporation)

I am an officer of the applicant corporation herein, and am authorized to make this verification on its behalf. The statements in the foregoing document are true of my own knowledge, except as to the matters which are therein stated on information and belief, and as to those matters I believe them to be true.

I declare under penalty of perjury under California law that the foregoing is true and correct.

Executed on ____________________ (date) ____________________ at ____________________ (name of city), California.

DATED:

Respectfully Submitted,

____________________

Signature

1. New section filed 2-1-93; operative 2-1-93 (Register 93, No. 6).

Note: Authority cited: Sections 1861.10, 12921 and 12926, Insurance Code. Reference: Sections 1861.05(b) and (c), 1861.08 and 1861.10(a), (b), Insurance Code; and CalFarm Insurance Company, et al. v. George Deukmejian, et al., 48 Cal.3d 805 (1989).