DEPARTMENT OF REVENUE AND REGULATION
DIVISION OF INSURANCE
SEE: § 20:06:38:13
Source: 24 SDR 33, effective September 22, 1997.
I certify that I displayed a computer screen illustration for ______________________ that complies with state requirements and for which no hard copy was furnished. The illustration was based on the following personal and policy information:
1. Gender Male _____ Female _____
2. Age _______________________________
3. Underwriting or rating class _______________________________
4. Type of policy _______________________________
5. Type of rider _______________________________
6. Initial death benefit _______________________________
7. Dividend option election _______________________________
(or application of non-
guaranteed elements, if
8. Guaranteed interest rate(s) _______________________________
9. Nonguaranteed interest rate(s) _______________________________
I acknowledge that I viewed a computer screen illustration based on the information as stated above. No hard copy of the illustration was furnished. I understand that an illustration conforming to the policy as issued will be provided to me no later than at the time the policy is delivered.
An illustration conforming to the requirements of the model must be prepared and personally delivered by the agent on or before delivery of the policy.
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