Advertising Compliance Form

TO: Insurance Companies Writing Life Insurance And Annuities

FROM: Missouri Department Of Insurance, Financial Institutions & Professional Registration

RE: Annual Statement Filing

Certificate Of Compliance With Advertising Rules

Missouri Regulation 20 CSR 400-5.100(8)(B) requires all insurance companies, which issue life insurance contracts and/or annuities in the State of Missouri, to file with the Director with its Annual Statement a certificate indicating that the company’s advertisements complied with Missouri Regulation 20 CSR 400-5.100. The certificate should be in a form substantially similar to the language stated on the reverse side of this folio. The regulation requires that an authorized officer of the company, who has knowledge of the company’s compliance with this regulation, execute this certificate. For any questions, please contact Mike Woolbright (573-526-2933) at the Market Conduct Examination Section of the Missouri Department of Insurance, Financial Institutions & Professional Registration.

STATE OF _______________________

COUNTY OF _____________________

AFFIDAVIT

CERTIFICATE OF COMPLIANCE WITH ADVERTISING RULES

Before me, the undersigned authority, personally appeared _______________________ who, being by me duly sworn and deposed, stated as follows:

1. My name is ___________________________ and I am of sound mind, capable of making this affidavit and personally acquainted with the facts herein stated.
2. I am an officer of the __________________________ Insurance Company, an entity authorized to sell life insurance and/or annuities in the State of Missouri.
3. I am authorized to make this affidavit on behalf of the _________________________ Insurance Company.
4. I am knowledgeable about the requirements contained in Missouri Regulation 20 CSR 400-5.100.
5. To the best of my knowledge, information and belief, the advertisements which were disseminated by or on behalf of the _______________________________ Insurance Company during the calendar year prior to the date of this affidavit complied or were made to comply in all respects with the provisions of Missouri Regulation 20 CSR 400-5.100.

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Signature of Authorized Officer

In witness whereof, I have hereunto subscribed my name and affixed my official seal this ___ day of ____________ of 20___.

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Signature of Notary (seal)