N.Y. Comp. Codes R. & Regs. tit. 11 § 52.62
To comply with section 52.54 of this Part, policies of individual insurance meeting the definition of section 52.10 of this Part, which provide only dental insurance coverage, shall use the following statement only, except that appropriate policy identification may be included:
COMPANY NAME
DENTAL INSURANCE
REQUIRED DISCLOSURE STATEMENT
This policy provides dental insurance only and pays for dental care subject to a copayment by you of to ________%[FN*] and a deductible of ($ to ________ per person)[FN**] ($________ per family) ($________ per year) ($ ________ per benefit period) and a total maximum of $________
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 ________%. This ratio is the portion of future premiums which the company expects to return as benefits, when averaged over all people with this policy.
[FN*] Omit reference to year if, in lieu of dollar amounts, deductibles and fractions of the deductibles are set forth in the summary.
[FN**] In lieu of listing specific dollar amounts, insurers may refer to the Part A or Part B deductibles and appropriate fractions thereof.
N.Y. Comp. Codes R. & Regs. Tit. 11 § 52.62