Each company shall submit a "Certificate of Compliance" in substantially this format:
CERTIFICATE OF COMPLIANCE
______________________________________________________________
(Company Name)
By: ______________________ Title: ________________________________
certifies that the policy forms submitted or referenced in this filing do comply:
and does further certify to the best of our knowledge and belief that:
In utilizing the procedure for policy form filing and approval set forth in 50 Ill. Adm. Code 916, ______________(company name)______________hereby expressly agrees and consents to a review, by the______ Director, to be made at any time, and further hereby expressly agrees and consents to the discontinuance by the company of future use of the approved policy forms, 30 days from the date of mailing an order of withdrawal issued by the Director pursuant to Section 143(1) of the Illinois Insurance Code. The order shall set forth the reasons why the previously approved policy forms are violative of or contrary to the provisions of the Illinois Insurance Code or all provisions of 50 Ill. Adm. Code applicable to policy forms. Each company shall have the right to request a hearing within that 30 day period. The request shall be made in writing to the Director. The order of withdrawal shall be stayed and the company shall be given a hearing under the provisions of Sections 143(1), 401(c), 401.1, 402(2), 426 and 429 of the Illinois Insurance Code [215 ILCS 5/143(1), 401(c), 401.1, 402(2), 426 and 429] and 50 Ill. Adm. Code 2402, as may be applicable, to determine:
______________________________________________________
(Company Name)
By: ___________________________________________________
(Signature)
Title: ________________________________ Date: _____________
Ill. Admin. Code tit. 50, pt. 916, exh. A