
STATE OF ARKANSAS
DEPARTMENT OF INSURANCE
FINANCE DIVISION
1200 West Third Street
Little Rock, Arkansas 72201
(501) 371-2665
I, _________________________________, ____________________hereby certify that to the best of my
(Name of Authorized Officer) (Title)
knowledge, information and belief, the advertisements (if any) pertaining to life insurance, which were disseminated by :
__________________________________________________________
(Name of Company)
during the period of January 1, _____
through December 31, ______, complied or were made to comply in all respects
with the provisions of these Rules and Regulations and the laws of the State of
Dated at ________________________ in the State of _______________________ this ______ day of _________________, 2______.
___________________________________
Authorized Officer of the Company