"Connecticut Insurance Data Security Law Exception Certification Form" - Connecticut

Connecticut Insurance Data Security Law Exception Certification Form is a legal document that was released by the Connecticut Insurance Department - a government authority operating within Connecticut.

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STATE OF CONNECTICUT
INSURANCE DEPARTMENT
CONNECTICUT INSURANCE DATA SECURITY LAW
EXCEPTION CERTIFICATION FORM
CONTACT INFORMATION
Licensee:
________________________________________________________
NAIC #:
________________________________________________________
Contact Name: ________________________________________________________
Title:
________________________________________________________
Phone:
________________________________________________________
Email:
________________________________________________________
EXCEPTIONS
I certify that the above named licensee is in possession of protected health information
subject to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and has
established and maintains programs and procedures regarding information privacy, security, and
breach notification that are prescribed by HIPAA and by Parts 160 and 164 of Title 45 of the Code
of Federal Regulations established pursuant to HIPAA.
I certify that the above named licensee is in compliance with N.Y. Comp. Codes R. &
Regs. Title 23, section 500, Cybersecurity Requirements for Financial Services Companies,
effective March 1, 2017.
AFFIRMATION
I subscribe and affirm, under penalty of perjury, that the statements made in this form have been
examined by me and to the best of my knowledge and belief are true, correct and complete, and
that I am duly authorized to execute this affirmation.
(Authorized Representative - Signature)
___________________________________
(Printed Name)
portal.ct.gov/cid
P.O. Box 816 Hartford, CT 06142-0816
An Equal Opportunity Employer
STATE OF CONNECTICUT
INSURANCE DEPARTMENT
CONNECTICUT INSURANCE DATA SECURITY LAW
EXCEPTION CERTIFICATION FORM
CONTACT INFORMATION
Licensee:
________________________________________________________
NAIC #:
________________________________________________________
Contact Name: ________________________________________________________
Title:
________________________________________________________
Phone:
________________________________________________________
Email:
________________________________________________________
EXCEPTIONS
I certify that the above named licensee is in possession of protected health information
subject to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and has
established and maintains programs and procedures regarding information privacy, security, and
breach notification that are prescribed by HIPAA and by Parts 160 and 164 of Title 45 of the Code
of Federal Regulations established pursuant to HIPAA.
I certify that the above named licensee is in compliance with N.Y. Comp. Codes R. &
Regs. Title 23, section 500, Cybersecurity Requirements for Financial Services Companies,
effective March 1, 2017.
AFFIRMATION
I subscribe and affirm, under penalty of perjury, that the statements made in this form have been
examined by me and to the best of my knowledge and belief are true, correct and complete, and
that I am duly authorized to execute this affirmation.
(Authorized Representative - Signature)
___________________________________
(Printed Name)
portal.ct.gov/cid
P.O. Box 816 Hartford, CT 06142-0816
An Equal Opportunity Employer
NOTARIZATION
STATE of
___________________________________
SS
COUNTY of _____________________________
Personally appeared on this __________ day of ___________, 20___, _____________________
signer and sealer of the foregoing instrument, acknowledged same to be his/her free act and deed
before me.
(SEAL)
__________________________________________________
(Notary Public/Commissioner of the Superior Court Signature)
_________________________________________________
(Printed Name)
Commission Expires:________________________________
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