The following illustrates an acceptable statement to be filed when the opining actuary or pre-approved individual has indicated reliance on data provided by company personnel:

I [name of officer], [title], of [name of carrier], hereby affirm that the listings (summaries, rate manuals, etc.) of relevant data prepared for and submitted to [name of appointed actuary] were prepared under my direction and, to the best of my knowledge and belief, are substantially accurate and complete.

Name of Officer of the Carrier (typewritten)

Signature of Officer of the Carrier

Date