If the appointed actuary does not express an opinion as to the accuracy and completeness of the listings and summaries of policies in force, there should be attached to the opinion the statement of a company officer or accounting firm who prepared such underlying data similar to the following:

I, [name of officer], [title] of [name and address of Company or accounting firm], hereby affirm that the listings are summaries of policies and contracts in force as of December 31, [ ], prepared for and submitted to [name of appointed actuary], were prepared under my direction and, to the best of my knowledge and belief, are substantially accurate and complete.

[Signature of the Officer of the Company or Accounting Firm]

[Address of the Officer of the Company or Accounting Firm]

[Telephone Number of the Officer of the Company or Accounting Firm]