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font-family: 'Arial', 'sans-serif'; font-size: 12pt; line-height: 108%; margin-top: 0; margin-left: 0; margin-right: 0; margin-bottom: .001pt; } span.s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont-000022 { font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </style></head><body><div><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">DEPARTMENT OF LABOR AND REGULATION</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">DIVISION OF INSURANCE</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">PARTNERSHIP CERTIFICATION FORM</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Chapter 20:</span><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">06:21</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">APPENDIX L</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">SEE: § </span><a href="https://sdlegislature.gov/Rules?Rule=20:06:21:78"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont-000002">20:06:21:78</span></a></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">    </span><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont-000004">Source:</span><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont"> 33 SDR 230, effective </span><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">July 2, 2007.</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont-000005"><br />&#x200e;</span><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont-000004">LONG-TERM CARE PARTNERSHIP</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000006"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000001"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont-000004">CERTIFICATION FORM</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">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></p><div class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000007"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></div><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">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 "2000 Model Regulation" and "2000 Model Act," respectively).</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000008"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont-000009">Part I:</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Name of Insurer    ___________________________________________</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Company NAIC #    ___________________________________________</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Address        ___________________________________________</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">            ___________________________________________</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">            ___________________________________________</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Telephone        ___________________________________________</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Company Contact</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Name            ___________________________________________</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Title            ___________________________________________</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Telephone        ___________________________________________</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">E-Mail            ___________________________________________</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont-000004">Part II:</span></p><div class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000007"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000003"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></div><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">2000 NAIC MODEL REGULATION AND 2000 NAIC MODEL ACT</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">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></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">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></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><div align="left"><table dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000010"><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000011"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText-000012"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">NAIC Model Regulation Requirement</span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000013"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText-000012"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Identify Policy Page # and Provision OR use this space to explain if requirement is inapplicable</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText-000012"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000014"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText-000015"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">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></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText-000015"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000016"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000014"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText-000015"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 6B (relating to prohibitions on limitations and exclusions) other than paragraph (7) thereof.</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText-000015"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000016"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000014"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 6C (relating to extension of benefits).</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000016"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000014"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 6D (relating to continuation or conversion of coverage).</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000016"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000014"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 6E (relating to discontinuance and replacement of policies).</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000016"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000014"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 7 (relating to unintentional lapse).</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000016"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000014"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 8 (relating to disclosure), other than sections 8F, 8G, 8H, and 8I thereof.</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000016"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000014"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 9 (relating to required disclosure of rating practices to consumer).</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000016"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000014"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 11 (relating to prohibitions against post-claims underwriting).</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000016"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000014"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 12 (relating to minimum standards).</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000016"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000014"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 14 (relating to application forms and replacement coverage).</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000016"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000014"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 15 (relating to reporting requirements).</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000016"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000014"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 22 (relating to filing requirements for marketing).</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000016"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000014"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 23 (relating to standards for marketing, including inaccurate completion of medical histories, other than paragraphs (1), (6), and (9) of section 23C).</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000016"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000014"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 24 (relating to suitability).</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000016"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000014"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 25 (relating to prohibition against preexisting conditions and probationary periods in replacement policies or certificates).</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000016"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000014"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">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></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000016"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000014"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 29 (relating to standard format outline of coverage).</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000016"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000014"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 30 (relating to requirement to deliver shopper's guide).</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000016"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr></table></div><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><div align="left"><table dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000010"><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000017"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">NAIC Model Act Requirement</span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000018"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Identify Policy Page # and Provision OR use this space to explain if requirement is inapplicable</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000019"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 6C (relating to preexisting conditions).</span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000020"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000019"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 6D (relating to prior hospitalization).</span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000020"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000019"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 8 (relating to contingent nonforfeiture benefits).</span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000020"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000019"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 6F (relating to right to return).</span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000020"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000019"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 6G (relating to outline of coverage).</span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000020"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000019"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 6H (relating to requirements for certificates under group plans).</span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000020"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000019"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 6J (relating to policy summary).</span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000020"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000019"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 6K (relating to monthly reports on accelerated death benefits).</span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000020"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr><tr><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000019"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Section 7 (relating to incontestability period).</span></p></td><td class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000020"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></td></tr></table></div><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont-000004">Part III. INFLATION PROTECTON</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000006"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">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 </span><a href="https://sdlegislature.gov/Rules?Rule=20:06:21:76"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont-000002">20:06:21:76</span></a><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">:</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">_______________________________________________________________________________</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal-000021"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">_______________________________________________________________________________</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">_______________________________________________________________________________</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">_______________________________________________________________________________</span></p><div class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000007"><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></div><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont-000004">Part IV.</span><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont"> CERTIFICATION</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">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></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">________________________        _____________________________________</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Date                                    Name and title of officer of the Insurer</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">________________________        _____________________________________</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont">Date                                    Signature of officer of the Insurer</span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eBodyText"><span class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eDefaultParagraphFont-000022"><br />&#x200e;</span><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p><p dir="ltr" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916eNormal"><span xml:space="preserve" class="s3268288d-be78-4f1b-aa8f-3db2a5e8916e000000"> </span></p></div></body></html>