"Certification Form" - Pennsylvania

This Pennsylvania-specific "Certification Form" is a document released by the Pennsylvania Insurance Department.

Download the fillable PDF by clicking the link below and use it according to the applicable legal guidelines.

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Download "Certification Form" - Pennsylvania

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CERTIFICATION
I hereby certify that the below-referenced policy form submission and related rate filing, required
to be in compliance with the requirements of the Patient Protection and Affordable Care Act,
P.L. 111-148,124 Stat. 119, and the Health Care and Education Reconciliation Act of 2010, P.L.
111-152, 124 Stat. 1051, together and as modified referred to as the ACA, have been drafted or
modified to be in compliance with the ACA and the regulations promulgated thereunder.
I am aware that accident and health rates and forms may be disapproved, or otherwise give rise
to remedies or sanctions, if they fail to comply with applicable law or regulations. See, e.g., 40
P.S. §3801.304(b); 40 P.S. §1171.5(a)(5)(prohibiting knowingly filing a false statement of
material fact with a supervisory or public official).
I hereby warrant that I have full, complete and final authority to attest to the representations of
the Company as set forth herein, and do hereby attest that the representations set forth in this
Compliance Checklist and Certification Form are true, correct and complete.
Policy Form # ______________________________________
Date
Name and Title of Authorized Representative of the
Company
CERTIFICATION
I hereby certify that the below-referenced policy form submission and related rate filing, required
to be in compliance with the requirements of the Patient Protection and Affordable Care Act,
P.L. 111-148,124 Stat. 119, and the Health Care and Education Reconciliation Act of 2010, P.L.
111-152, 124 Stat. 1051, together and as modified referred to as the ACA, have been drafted or
modified to be in compliance with the ACA and the regulations promulgated thereunder.
I am aware that accident and health rates and forms may be disapproved, or otherwise give rise
to remedies or sanctions, if they fail to comply with applicable law or regulations. See, e.g., 40
P.S. §3801.304(b); 40 P.S. §1171.5(a)(5)(prohibiting knowingly filing a false statement of
material fact with a supervisory or public official).
I hereby warrant that I have full, complete and final authority to attest to the representations of
the Company as set forth herein, and do hereby attest that the representations set forth in this
Compliance Checklist and Certification Form are true, correct and complete.
Policy Form # ______________________________________
Date
Name and Title of Authorized Representative of the
Company
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