(Company Name) Certification of Information Annual Reinsurance Data Call Florida Office of Insurance Regulation (Office) Reporting for the Year ______ Part # ____ I, do hereby certify that I (Name of Company Officer Must be NAIC recognized) , – am currently the of and (Title) (Company Name) as such do hereby certify that the responses on the attached report are true and accurate regarding the Company’s Compliance with the examination being conducted by the Office for the collection of data regarding annual reinsurance purchases. Signature of Company Officer Date Title Must be an NAIC- recognized officer – Subscribed and sworn to before me on this day of , 20 (Notary Notary Public Signature), (Please include your printed name, ink stamp or highlighted seal)
(Company Name) Certification of Information Annual Reinsurance Data Call Florida Office of Insurance Regulation (Office) Reporting for the Year ______ Part # ____ I, (Name of Company Officer – Must be NAIC recognized) , do hereby certify that I am currently the (Title) of (Company Name) and as such do hereby certify that the responses on the attached report are true and accurate regarding the Company’s Compliance with the examination being conducted by the Office for the collection of data regarding annual reinsurance purchases. Signature of Company Officer Date Title – Must be an NAIC- recognized officer Subscribed and sworn to before me on this day of , 20 (Notary Signature), Notary Public (Please include your printed name, ink stamp or highlighted seal)
ARDC_NotarizedAffidavit.docx