Ins 6.05(4)(a)7.7. A copy of the previously approved form clearly marked “for reference only” if the current form is to supercede the previously approved form. Ins 6.05(4)(a)8.8. If the submission of forms is filed by a third-party on behalf of an insurer, a letter from the insurer, authorizing the third-party to file forms on its behalf. Ins 6.05(4)(a)9.9. A self-addressed return envelope of sufficient size to return one copy of the materials in subds. 1. and 6., to the insurer. Ins 6.05(4)(b)(b) Each electronic submission of forms shall include all of the following: Ins 6.05(4)(b)2.2. A properly completed certificate of compliance and readability in substantially identical format as in Appendix A. Ins 6.05(4)(b)3.3. A filing letter that contains all of the following information: Ins 6.05(4)(b)3.a.a. In the case of a form that alters or replaces a previously filed form, a description of the changes. Ins 6.05(4)(b)3.b.b. The form number and approval or filing date of any form superseded by the new form. Ins 6.05(4)(b)4.4. One copy of each form in final electronic format exactly as it will be offered for issuance or delivery in the state of Wisconsin, except for hypothetical data and other appropriate variable material. Ins 6.05(4)(b)5.5. If a form contains variable material or language, a written description identifying the range of the variable material or language. Ins 6.05(4)(b)6.6. A copy of the previously approved or filed form clearly marked “for reference only” if the current form is to supersede the previously approved or filed form. Ins 6.05(4)(b)7.7. If the submission of forms is filed by a third-party on behalf of an insurer, a letter from the insurer authorizing the third-party to file forms on its behalf. Ins 6.05(4)(c)(c) A submission filed by a rate service organization will be considered as filed on behalf of all affiliated insurers. Ins 6.05(5)(5) Insurer records. Each insurer shall maintain a file of all forms approved or filed under s. 631.20, Stats., for use in Wisconsin until all exposure on the risks insured against has terminated. The file is subject to examination and the commissioner may request that any portion of the file be available for review within ten days of a written request. Ins 6.05(6)(6) Incomplete filing. The commissioner shall reject without further review any filing which does not include all of the items in sub. (4) (a) and (b). Ins 6.05(7)(7) Penalty. Insurers violating the provision of this rule by using unapproved or unfiled forms shall be subject to the penalties in s. 601.64, Stats. Each form issued to an individual policyholder shall constitute a separate violation. Ins 6.05 HistoryHistory: Cr. Register, July, 1958, No. 31, eff. 8-1-58; am. (3), Register, May, 1975, No. 233, eff. 6-1-75; emerg. am. (1), eff. 6-22-76; am. (1), Register, September, 1976, No. 249, eff. 10-1-76; r. and recr. Register, November, 1977, No. 263, eff. 12-1-77; r. and recr. (4), Register, January, 1980, No. 289, eff. 2-1-80; am. (4) (a), (b) (intro.) and 7., Register, February, 1982, No. 314, eff. 3-1-82; cr. (4) (c) and (d), Register, July, 1982, No. 319, eff. 8-1-82; r. and recr. December, 1987, No. 384, eff. 1-1-88; r. (5), renum. (6) to (8) to be (5) to (7), Register, July, 1989, No. 403, eff. 8-1-89; CR 10-076: am. (3) (b), (4) (a) (intro.), 1. to 5., 8., 9., (5), (6), (7), renum. (3) (d), (e), (f) to be (3) (f), (d), (e) and am., renum. (4) (b) to be (4) (c), cr. (4) (b) Register January 2011 No. 661, eff. 2-1-11. Ins 6.05 Appendix A
CERTIFICATE OF COMPLIANCE AND READABILITY
I __________________________, (name), an officer of____________________(company name), hereby certify that I have authority to bind and obligate the company by filing this (these) form(s). I further certify that, to the best of my information, knowledge and belief:
1. The accompanying form(s) as identified by the attached listing comply(ies) with all applicable provisions of the Wisconsin Statutes and with all applicable administrative rules of the Commissioner of Insurance;
2. The form(s) does (do) not contain any inconsistent, ambiguous, or misleading clauses;
3. The form(s) does (do) not contain specification or conditions that unreasonably or deceptively limit the risk purported to be assumed in the general coverage of the policy form(s);
4. The only variations from a form currently on file with the commissioner of insurance and the only unconventional policy provisions are clearly marked or otherwise indicated pages __________________ of the attached form(s) or in an attachment; and
5. The attached form(s) is (are) in final printed format or typed facsimile and is (are) as will be offered for issuance or delivery in Wisconsin after approval by the Commissioner of Insurance, except for hypothetical data and other appropriate variable material.
6. If this form is a consumer insurance policy, the text of the form(s) meet(s) the minimum reading ease score or, if authorized by the commissioner, the score is lower than the minimum required by s. Ins 6.07 (4) (a) 1., Wis. Adm. Code. Product used to determine the Flesch score:____________________. I understand that the commissioner of insurance will rely on this certification regarding the forms filed, and should it be determined that the policy form(s) does(do) not comply with the applicable laws, regulations, filing requirements and product standards or that this certification is materially false or incorrect, appropriate corrective and disciplinary action, including retroactive disapproval, as authorized by law, may be taken by the commissioner against the company and the officer completing this certification.
(signature)
(title)
(date)
Individual responsible for this filing:
Name: Title:_________________________
Address: ________________
Phone Number:_______________ Date: