Ill. Admin. Code tit. 50, § 3801.ILLUSTRATION A – Actuarial Certification

The following illustrates an acceptable actuarial certification:

(name) am an officer/employee of

(carrier

name) OR am associated with the firm of

(employer name)

and am a member of the American Academy of Actuaries and meet the Qualification Standards appropriate for this certification.

(or)

(name) am an officer/employee of

(carrier

name) OR am associated with the firm of

(employer name)

and am not a member of the American Academy of Actuaries. I meet the definitional standards of the "Other Individual Acceptable to the Director" and have received the Director's prior

approval on

(date) pursuant to 50 Ill. Adm. Code 3801.30.

I am completing the small employer carrier actuarial certification for

(carrier name). I am familiar with the applicable statutory provisions of 215 ILCS 93/1 through 99 and requirements of 50 Ill. Adm. Code 3801 and the Company Bulletins issued by the Director of Insurance.

This certification is for the period from

through

I relied on listings (summaries, rate manuals, etc.) of relevant data prepared by

(name and title of company officer responsible for preparing the underlying records). Attached is a (are) statement(s) by the indicated company officer(s) on whom I relied.

The Carrier had

separate class(es) of business at the end of the certification

period. (If more than one, list the classes and the substantial differences which qualified each as a separate class. For each class, list the criteria by which groups are assigned to the class.)

The Carrier had small employer group annual premium volume of $

in force

at the end of the certification period. I tested the rates of small employer groups whose annual

premium volume totaled $

to verify that the rates actually charged were in

accordance with the rating manual(s).

Based upon my review, I find that the small employer carrier

(was or was

not) in compliance with Section 25 of the Small Employer Health Insurance Rating Act [215 ILCS 93/25]. (If not in compliance, include required additional paragraph, detail of instances of noncompliance and a description of the small employer carrier's plan to correct the areas of noncompliance.)

In other respects, my examination included a review of the actuarial methods in order to assure that the rating methods of the small employer carrier were actuarially sound.

Actuarial methods, considerations and analysis used in forming my opinion to conform the appropriate Actuarial Standards Board's Standards of Practice (ASOP), which form the basis of the statement of opinion.

Actuary name or the pre-approved individual's name (typewritten)

Signature

Date