1. a) with all provisions of the Illinois Insurance Code applicable to the policy forms; and

2. b) with all provisions of 50 Ill. Adm. Code applicable to policy forms;

   and does further certify to the best of our knowledge and belief that:

3. 1) the forms do not contain any inconsistent, ambiguous or misleading clauses;
4. 2) the forms do not contain specifications or conditions that unreasonably or deceptively affect the risk purported to be assumed in the general coverage of the policy forms;
5. 3) the only variation from the usual provisions of the policy forms are clearly marked or otherwise indicated;
6. 4) the language of the policy form, as submitted or approved, shall be exactly as it has been or will be offered for issuance or delivery in the State of Illinois as approved by the Director, except for hypothetical data and other appropriate variable material; and

7. 5) the policy forms do not contain any provision or clause currently being disapproved by the Director.

   In utilizing the procedure for policy form filing and approval set forth in 50 Ill. Adm. Code 916,
   (company name)	hereby expressly agrees and consents to a review, by the
   Director, to be made at any time, and further hereby expressly agrees and consents to the discontinuance by the company of future use of the approved policy forms, 30 days from the date of mailing an order of withdrawal issued by the Director pursuant to Section 143(1) of the Illinois Insurance Code. The order shall set forth the reasons why the previously approved policy forms are violative of or contrary to the provisions of the Illinois Insurance Code or all provisions of 50 Ill. Adm. Code applicable to policy forms. Each company shall have the right to request a hearing within that 30 day period. The request shall be made in writing to the Director. The order of withdrawal shall be stayed and the company shall be given a hearing under the provisions of Sections 143(1), 401(c), 401.1, 402(2), 426 and 429 of the Illinois Insurance Code [215 ILCS 5/143(1), 401(c), 401.1, 402(2), 426 and 429] and 50 Ill. Adm. Code 2402, as may be applicable, to determine:

8. a) whether the policy form shall be disapproved; and

9. b) whether further orders of the Director may be appropriate.

   (Company Name)
   By:
   (Signature)
   Title:		Date:

Each company shall submit a "Certificate of Compliance" in substantially this format:

certifies that the policy forms submitted or referenced in this filing do comply:

(Source: Amended at 39 Ill. Reg. 16152, effective December 3, 2015)