New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 2 - INSURANCE GROUP
Subchapter 36 - RISK RETENTION GROUPS AND PURCHASING GROUPS
Appendix E
POLICY FORM CERTIFICATION
I ................................, hereby certify that
(Name)
I am the .................................., an officer
(Title)
of .............................., and am authorized to
(Name of insurer)
execute this certified statement on behalf of the insurer.
| I further certify that the policy form(s) and rating system issued to | |
| .......................... has been filed with | |
| (Purchasing Group) | |
the New Jersey Department of Banking and Insurance, if required by law, and are otherwise in compliance with N.J.S.A. 17:29AA-1 et seq., N.J.A.C. 11:13-1, and N.J.S.A. 17:22-6.4 3.
I further certify that I am aware that the New Jersey Department of Banking and Insurance will rely on this certification in connection with the registration of the above referenced Purchasing Group.
.....................................................................
(Signature)
.....................................................................
(Date)
