<html> <head> <title>Rule 20:06:21:0L Partnership Certification Form.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:21:0L"> <META NAME="Description" Content="Administrative Rules 20:06:21:0L Partnership Certification Form."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; font-size:12.0pt; font-family:"Times New Roman","serif";} p.MsoBodyText, li.MsoBodyText, div.MsoBodyText {mso-style-link:"Body Text Char"; margin:0in; margin-bottom:.0001pt; font-size:10.0pt; font-family:"Arial","sans-serif";} span.BodyTextChar {mso-style-name:"Body Text Char"; mso-style-link:"Body Text"; font-family:"Arial","sans-serif";} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.0in 1.0in 1.0in;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US> <div class=WordSection1> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>DEPARTMENT OF LABOR AND REGULATION</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>DIVISION OF INSURANCE</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>PARTNERSHIP CERTIFICATION FORM</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Chapter 20:06:21</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>APPENDIX L</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>SEE: &#167; 20:06:21:78</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b><span style='font-weight:bold'>Source:</span></b> 33 SDR 230, effective July 2, 2007.</font></p> <font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'><br clear=all style='page-break-before:always'> </span></font> <p class=MsoNormal align=center style='text-align:center'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>LONG-TERM CARE PARTNERSHIP</span></font></b></p> <p class=MsoNormal align=center style='text-align:center'><b><font size=3 face="Times New Roman">&nbsp;</font></b></p> <p class=MsoNormal align=center style='text-align:center'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>CERTIFICATION FORM</span></font></b></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Note: This Form must be completed and submitted with each long-term care policy or certificate form for which the insurer is seeking partnership qualification. A separate form must be completed for each policy form and a specimen copy of the form, including all riders and endorsements, must be attached. A long-term care policy or certificate form may not be issued in South Dakota as a partnership policy or certificate unless and until this form has been submitted to and approved by the Division of Insurance.</span></font></p> <div style='border:none;border-bottom:double windowtext 4.5pt;padding:0in 0in 1.0pt 0in'> <p class=MsoNormal style='text-align:justify;border:none;padding:0in'><font size=3 face="Times New Roman">&nbsp;</font></p> </div> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Under section 1917(b)(5)(B)(iii) of the Social Security Act (42 U.S.C. 1396p(b)(5)(iii)) and in accordance with applicable South Dakota requirements, the insurer hereby submits information relating to policy or certificate form _____________ (form number) to substantiate that the form includes all required consumer protection requirements set forth in section 1917(b)(5)(A) of the Social Security Act (42 U.S.C. 1396p(b)(5)(A)) and that it includes certain specified provisions of the Long-Term Care Insurance Model Regulation and Long-Term Care Insurance Model Act promulgated by the National Association of Insurance Commissioners (adopted as of October 2000) (referred to herein as the &quot;2000 Model Regulation&quot; and &quot;2000 Model Act,&quot; respectively).</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><b><font size=2 face="Times New Roman"><span style='font-size:11.0pt;font-weight:bold'>Part I:</span></font></b></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Name of Insurer&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ___________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Company NAIC #&nbsp;&nbsp;&nbsp; ___________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Address&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ___________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ___________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ___________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Telephone&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ___________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Company Contact</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Name&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ___________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Title&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ___________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Telephone&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ___________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>E-Mail&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ___________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>Part II:</span></font></b></p> <div style='border:none;border-bottom:double windowtext 4.5pt;padding:0in 0in 1.0pt 0in'> <p class=MsoNormal style='text-align:justify;border:none;padding:0in'><font size=3 face="Times New Roman">&nbsp;</font></p> </div> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>2000 NAIC MODEL REGULATION AND 2000 NAIC MODEL ACT</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Note to Insurer: Identify the page and/or provision within the policy or certificate form that addresses each requirement, or, if inapplicable, use the space identified to explain.</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Policy/Certificate form ________________ meets the following requirements of the 2000 NAIC Model Long-Term Care Regulation and/or 2000 NAIC Model Long-Term Care Act, as indicated below:</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <table class=MsoNormalTable border=1 cellspacing=0 cellpadding=0 style='border-collapse:collapse;border:none'> <tr> <td width=381 valign=top bgcolor="#E6E6E6" style='width:285.9pt;border:solid windowtext 1.0pt; background:#E6E6E6;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>NAIC Model Regulation Requirement</span></font></p> </td> <td width=269 valign=top bgcolor="#E6E6E6" style='width:201.55pt;border:solid windowtext 1.0pt; border-left:none;background:#E6E6E6;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Identify Policy Page # and Provision OR use this space to explain if requirement is inapplicable</span></font></p> <p class=MsoBodyText align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=381 valign=top style='width:285.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 6A (relating to guaranteed renewal or noncancellability), other than paragraph (5) thereof, and the requirements of section 6B of the 2000 Model Act relating to such section 6A.</span></font></p> <p class=MsoBodyText><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=269 valign=top style='width:201.55pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=381 valign=top style='width:285.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 6B (relating to prohibitions on limitations and exclusions) other than paragraph (7) thereof.</span></font></p> <p class=MsoBodyText><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=269 valign=top style='width:201.55pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=381 valign=top style='width:285.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 6C (relating to extension of benefits).</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=269 valign=top style='width:201.55pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=381 valign=top style='width:285.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 6D (relating to continuation or conversion of coverage).</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=269 valign=top style='width:201.55pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=381 valign=top style='width:285.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 6E (relating to discontinuance and replacement of policies).</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=269 valign=top style='width:201.55pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=381 valign=top style='width:285.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 7 (relating to unintentional lapse).</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=269 valign=top style='width:201.55pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=381 valign=top style='width:285.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 8 (relating to disclosure), other than sections 8F, 8G, 8H, and 8I thereof.</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=269 valign=top style='width:201.55pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=381 valign=top style='width:285.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 9 (relating to required disclosure of rating practices to consumer).</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=269 valign=top style='width:201.55pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=381 valign=top style='width:285.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 11 (relating to prohibitions against post-claims underwriting).</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=269 valign=top style='width:201.55pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=381 valign=top style='width:285.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 12 (relating to minimum standards).</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=269 valign=top style='width:201.55pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=381 valign=top style='width:285.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 14 (relating to application forms and replacement coverage).</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=269 valign=top style='width:201.55pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=381 valign=top style='width:285.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 15 (relating to reporting requirements).</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=269 valign=top style='width:201.55pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=381 valign=top style='width:285.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 22 (relating to filing requirements for marketing).</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=269 valign=top style='width:201.55pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=381 valign=top style='width:285.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 23 (relating to standards for marketing, including inaccurate completion of medical histories, other than paragraphs (1), (6), and (9) of section 23C).</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=269 valign=top style='width:201.55pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=381 valign=top style='width:285.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 24 (relating to suitability).</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=269 valign=top style='width:201.55pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=381 valign=top style='width:285.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 25 (relating to prohibition against preexisting conditions and probationary periods in replacement policies or certificates).</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=269 valign=top style='width:201.55pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=381 valign=top style='width:285.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 26 (relating to contingent nonforfeiture benefits, if the policyholder declines the offer of a nonforfeiture provision described in section 7702B(g)(4) of the Internal Revenue Code of 1986 (26 U.S.C. 7702B(g)(4)).</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=269 valign=top style='width:201.55pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=381 valign=top style='width:285.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 29 (relating to standard format outline of coverage).</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=269 valign=top style='width:201.55pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=381 valign=top style='width:285.9pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 30 (relating to requirement to deliver shopper's guide).</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=269 valign=top style='width:201.55pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> </table> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <table class=MsoNormalTable border=1 cellspacing=0 cellpadding=0 style='border-collapse:collapse;border:none'> <tr> <td width=382 valign=top bgcolor="#E6E6E6" style='width:286.6pt;border:solid windowtext 1.0pt; background:#E6E6E6;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>NAIC Model Act Requirement</span></font></p> </td> <td width=268 valign=top bgcolor="#E6E6E6" style='width:200.85pt;border:solid windowtext 1.0pt; border-left:none;background:#E6E6E6;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Identify Policy Page # and Provision OR use this space to explain if requirement is inapplicable</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=382 valign=top style='width:286.6pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 6C (relating to preexisting conditions).</span></font></p> </td> <td width=268 valign=top style='width:200.85pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=382 valign=top style='width:286.6pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 6D (relating to prior hospitalization).</span></font></p> </td> <td width=268 valign=top style='width:200.85pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=382 valign=top style='width:286.6pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 8 (relating to contingent nonforfeiture benefits).</span></font></p> </td> <td width=268 valign=top style='width:200.85pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=382 valign=top style='width:286.6pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 6F (relating to right to return).</span></font></p> </td> <td width=268 valign=top style='width:200.85pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=382 valign=top style='width:286.6pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 6G (relating to outline of coverage).</span></font></p> </td> <td width=268 valign=top style='width:200.85pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=382 valign=top style='width:286.6pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 6H (relating to requirements for certificates under group plans).</span></font></p> </td> <td width=268 valign=top style='width:200.85pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=382 valign=top style='width:286.6pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 6J (relating to policy summary).</span></font></p> </td> <td width=268 valign=top style='width:200.85pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=382 valign=top style='width:286.6pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 6K (relating to monthly reports on accelerated death benefits).</span></font></p> </td> <td width=268 valign=top style='width:200.85pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=382 valign=top style='width:286.6pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Section 7 (relating to incontestability period).</span></font></p> </td> <td width=268 valign=top style='width:200.85pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> </table> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoBodyText style='text-align:justify'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"; font-weight:bold'>Part III. INFLATION PROTECTON</span></font></b></p> <p class=MsoBodyText style='text-align:justify'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"; font-weight:bold'>&nbsp;</span></font></b></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Identify the policy provision or provide form number of endorsement or amendment form (and date of approval) for inflation protection coverage in compliance with ARSD 20:06:21:76:</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>_______________________________________________________________________________</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>_______________________________________________________________________________</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>_______________________________________________________________________________</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>_______________________________________________________________________________</span></font></p> <div style='border:none;border-bottom:double windowtext 4.5pt;padding:0in 0in 1.0pt 0in'> <p class=MsoBodyText style='text-align:justify;border:none;padding:0in'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </div> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoBodyText style='text-align:justify'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"; font-weight:bold'>Part IV.</span></font></b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'> CERTIFICATION</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>I hereby certify that the answers, accompanying documents, and other information set forth herein are, to the best of my knowledge and belief, true, correct, and complete and the policy [certificate] satisfies the requirements necessary for a qualified state long-term care insurance partnership policy in the State of South Dakota.</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>________________________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; _____________________________________</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Date&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Name and title of officer of the Insurer</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>________________________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; _____________________________________</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Date&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Signature of officer of the Insurer</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <b><font size=3 face="Times New Roman"><span style='font-size:12.0pt; font-family:"Times New Roman","serif";font-weight:bold'><br clear=all style='page-break-before:always'> </span></font></b> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> </div> </body> </html>