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

Connecticut Insurance Data Security Law Annual 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
ANNUAL CERTIFICATION FORM
I hereby certify that _______________________________________________ is duly organized under the
(Name of Insurer)
laws of the State of Connecticut and is in compliance with the requirements of the Insurance Data Security
Law set forth in Conn. Gen. Stat. §38a-38(c). I hereby acknowledge that for examination purposes, the
insurer named above shall maintain all records, schedules and data supporting this certificate for a period
of 5 years. To the extent an insurer has identified areas, systems, or processes that require material
improvement, updating, or redesign, the insurer shall document the identification and the remedial efforts
planned and underway to address
areas, systems or processes. Such documentation shall be available
such
for inspection by the commissioner.
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)
NOTARIZATION
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:________________________________
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
ANNUAL CERTIFICATION FORM
I hereby certify that _______________________________________________ is duly organized under the
(Name of Insurer)
laws of the State of Connecticut and is in compliance with the requirements of the Insurance Data Security
Law set forth in Conn. Gen. Stat. §38a-38(c). I hereby acknowledge that for examination purposes, the
insurer named above shall maintain all records, schedules and data supporting this certificate for a period
of 5 years. To the extent an insurer has identified areas, systems, or processes that require material
improvement, updating, or redesign, the insurer shall document the identification and the remedial efforts
planned and underway to address
areas, systems or processes. Such documentation shall be available
such
for inspection by the commissioner.
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)
NOTARIZATION
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:________________________________
portal.ct.gov/cid
P.O. Box 816 Hartford, CT 06142-0816
An Equal Opportunity Employer