31.07.03.04

.04 Certification Statement for Automobile Insurers.

A. Certification Statement for Insurers and Rating Organizations.

CERTIFICATION STATEMENT
REVIEW OF AUTOMOBILE RATING TERRITORIES

I, ____________________ , a duly authorized representative of _______________________ (insurer or rating organization), NAIC # ______ (if applicable), do hereby certify that the following information is true to the best of my knowledge and belief.

1. The use of territories as a factor in rating by the above-named (insurer or rating organization) has been reviewed within the previous 3 years; and

2. Use of the territories on file, or as set forth in this filing, are actuarially justified. I understand that the Maryland Insurance Administration will rely on this certification, and if it is determined that this certification is materially false or incorrect, the insurer may be subject to administrative action, including appropriate penalties.

________________ _______________________________________
Date Signature of Authorized Representative

Name of Authorized Representative:
    ____________________________________________________________________________

Title: ______________________________

Address of Insurer: _________________________________________________________

Mail certification statement to: P & C Rate and Form Unit, Maryland Insurance Administration, 200 St. Paul Place, Baltimore, MD 21202.

B. Certification Statement for Insurers Adopting the Certification Statement of a Rating Organization.

CERTIFICATION STATEMENT
REVIEW OF AUTOMOBILE RATING TERRITORIES

I, ______________ , a duly authorized representative of __________ insurer), NAIC # _____, do hereby certify that the following information is true to the best of my knowledge and belief.

1. #032; _____________(insurer) is a member of or subscriber to ______________ (rating organization), a licensed rating organization, and has authorized the Commissioner to accept filings from ______________ (rating organization) on its behalf or has filed to adopt _______________ (rating organization's) filings.

2. #032; ________________(insurer) has filed no deviations relating to territory from the automobile rate filings submitted by ____________(rating organization).

3. #032; _____________ (rating organization) has filed with the Commissioner the certification statement required by Insurance Article, §11-216 or 11-319, Annotated Code of Maryland, and COMAR 31.07.03.03.

4. #032; ____________________(insurer) hereby adopts the statements made in the certification statement.

I understand that the Maryland Insurance Administration will rely on this certification, and if it is determined that this certification is materially false or incorrect, the insurer may be subject to administrative action, including appropriate penalties.

______________ ______________________________________
    Date Signature of Authorized Representative

Name of Authorized Representative:
    ____________________________________

Title: _____________________________

Address of Insurer: ____________________

Mail certification statement to: P&C Rate and Form Unit, Maryland Insurance Administration, 200 St. Paul Place, Baltimore, MD 21202.