Form 2c - Uniform Certificate Of Authority Application Page 4
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4Applicant Company Name: _____________________________
NAIC No. _________________________
FEIN:
_________________________
Applicant Company Officers’ Certification and Attestation
One of the three officers (listed below) of the Applicant Company must read the following very carefully before signing:
1.
I hereby certify, under penalty of perjury, that I have read the application, that I am familiar with its contents, and
that all of the information, including the attachments, submitted in this application is true and complete. I am
aware that submitting false information or omitting pertinent or material information in connection with this
application is grounds for license discipline or other administrative action and may subject me, the Applicant
Company, or both, to civil or criminal penalties.
2.
I acknowledge that I am familiar with the insurance laws and regulations of the jurisdictions in which the
Applicant Company is licensed or to which the Applicant Company is applying for licensure.
3.
I acknowledge that I am the ______________________________of the Applicant Company, am authorized to
execute and am executing this document on behalf of the Applicant Company.
4.
I hereby certify under penalty of perjury under the laws of the applicable jurisdictions that all of the forgoing is
true and correct, executed at ________________________________.
_________________________
__________________________________
Date
Signature of President
__________________________________
Full Legal Name of President
__________________________
__________________________________
Date
Signature of Secretary
__________________________________
Full Legal Name of Secretary
_________________________
__________________________________
Date
Signature of Treasurer
__________________________________
Full Legal Name of Treasurer
__________________________________
Name of Applicant Company
_________________________
__________________________________
Date
Signature of Witness
__________________________________
Full Legal Name of Witness
Revised 12/19/14
2016 National Association of Insurance Commissioners
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FORM 2C
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