Form INS5001 "Life Insurance Company Certification of Filing Compliance With Orc 3916.05(B) and Oac Rule 3901-9-04" - Ohio

What Is Form INS5001?

This is a legal form that was released by the Ohio Department of Insurance - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2019;
  • The latest edition provided by the Ohio Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form INS5001 by clicking the link below or browse more documents and templates provided by the Ohio Department of Insurance.

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Download Form INS5001 "Life Insurance Company Certification of Filing Compliance With Orc 3916.05(B) and Oac Rule 3901-9-04" - Ohio

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Product Regulation
Ohio Department of Insurance
rd
50 W. Town St., 3
Fl.
Mike DeWine – Governor
Suite 300
Jillian Froment – Director
Columbus, OH 43215-4186
(614) 644-2644
Life Insurance Company Certification of Filing Compliance
www.insurance.ohio.gov
with ORC §3916.05(B) and OAC Rule 3901-9-04
Date:
Company Name:
NAIC Number:
To the Superintendent of Insurance:
The undersigned, being duly authorized by
(company name)
hereby certify that the applications filed with the Ohio Department of Insurance for all life policies currently used in Ohio and not
exempted by OAC Rule 3901-9-04(D), fully comply with the regulatory requirements relating to detection and prevention of stranger-
originated life insurance.
Signature:
Name (printed):
Title:
Telephone:
E-Mail:
Accredited by the National Association of Insurance Commissioners (NAIC)
INS5001 (Rev. 01/2019)
Page 1 of 1
Product Regulation
Ohio Department of Insurance
rd
50 W. Town St., 3
Fl.
Mike DeWine – Governor
Suite 300
Jillian Froment – Director
Columbus, OH 43215-4186
(614) 644-2644
Life Insurance Company Certification of Filing Compliance
www.insurance.ohio.gov
with ORC §3916.05(B) and OAC Rule 3901-9-04
Date:
Company Name:
NAIC Number:
To the Superintendent of Insurance:
The undersigned, being duly authorized by
(company name)
hereby certify that the applications filed with the Ohio Department of Insurance for all life policies currently used in Ohio and not
exempted by OAC Rule 3901-9-04(D), fully comply with the regulatory requirements relating to detection and prevention of stranger-
originated life insurance.
Signature:
Name (printed):
Title:
Telephone:
E-Mail:
Accredited by the National Association of Insurance Commissioners (NAIC)
INS5001 (Rev. 01/2019)
Page 1 of 1