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:

Ins 6.06(1)(1) Purpose. The purpose of this section is to establish the minimum supplementary rate information required to be submitted with rate filings to the commissioner. Statutes interpreted or implemented by this section are ss. 601.42 (1g), 625.01, 625.02 (3), and 625.11, Stats.

Ins 6.06(2)(2) Scope. Except as provided in sub. (4), any insurer or rate service organization which is subject to s. 625.13 (1), Stats., and is filing rates for any kind or line of direct insurance in this state shall include, in that filing, the supplementary rate information required by sub. (5) or (6).

Ins 6.06(3)(a)(a) A “frequency trend factor” means any factor which adjusts the past number of paid or incurred claims to reflect more accurately the number of claims that can be expected to develop during the period the proposed rates will be used.

Ins 6.06(3)(b)(b) A “loss adjustment factor” means any factor used to modify or adjust the actual losses paid or incurred during the period under examination or review.

Ins 6.06(3)(c)(c) A “loss development factor” means any factor used either to adjust the reported amount of incurred losses to include incurred but not reported losses or to correct errors in the estimation of loss reserves for reported claims that have not been paid, or both.

Ins 6.06(3)(d)(d) A “premium adjustment factor” means any factor used to modify or adjust the actual premiums earned during the period under examination or review.

Ins 6.06(3)(e)(e) A “rate level factor” means any factor that adjusts prior earned premiums to the premiums that would have been earned if the present rates had been in effect throughout the period under examination or review.

Ins 6.06(3)(f)(f) A “severity trend factor” means any factor which adjusts the past average claim amount to reflect more accurately the average claim amount that can be expected to develop during the period the proposed rates will be used.

Ins 6.06(4)(a)(a) Life and disability insurance as defined in s. Ins 6.75 (1), disability insurance as defined in s. Ins 6.75 (2) (c), title insurance as defined in s. Ins 6.75 (2) (h), mortgage guaranty insurance as defined in s. Ins 6.75 (2) (i), municipal bond insurance as defined in s. Ins 3.08 (3) (e), and worker’s compensation insurance as defined in s. Ins 6.75 (2) (k) are exempt from the provisions of this section.

Ins 6.06(4)(b)(b) All companies licensed under ch. 612, Stats., are exempt from the provisions of this section.

Ins 6.06(4)(c)(c) The commissioner may, upon written application, exempt an insurer from full or partial compliance with this rule.

Ins 6.06(5)(5) Supplemental rate information. A rate filing and accompanying supplemental rate information shall be appropriately organized for the kind, class or line of business for which the filing is being made. Except as provided in sub. (6), all rate filings shall include the following supplementary rate information:

Ins 6.06(5)(a)1.1. At least 3 separate and consecutive years of both Wisconsin and aggregate of all states’ experience showing: