N.Y. Comp. Codes R. & Regs. tit. 11 § 52.61
To comply with section 52.54 of this Part, policies of individual insurance meeting the definition of section 52.9 of this Part shall use the following statement only, except that appropriate policy identification may be included:
COMPANY NAME
ACCIDENT INSURANCE
REQUIRED DISCLOSURE STATEMENT
This policy provides insurance only for ACCIDENTS. It does NOT provide basic hospital, basic medical or major medical insurance, as defined by the New York State Insurance Department.
IMPORTANT NOTICE--THIS POLICY DOES NOT PROVIDE COVERAGE FOR SICKNESS.
This policy:
(Accurately list benefits, exclusions, reductions and limitations of the policy in a manner which does not encourage misrepresentation of the actual coverage provided.)
This disclosure statement is a very brief summary of your policy.
The policy itself sets forth the rights and obligations of both you and the Insurance Company. It is therefore important that you READ YOUR POLICY carefully.
The expected benefit ratio for this policy is to ________%. This ratio is the portion of future premiums which the company expects to return as benefits, when averaged over all people with this policy.
N.Y. Comp. Codes R. & Regs. Tit. 11 § 52.61