Ins 6.05(4)(a)1.1. A properly completed insurance transmittal document in duplicate. Ins 6.05(4)(a)2.2. A properly completed certificate of compliance and readability in substantially identical format as in Appendix A. Ins 6.05(4)(a)3.a.a. In the case of a form that alters or replaces a previously approved form, a description of the change. Ins 6.05(4)(a)3.b.b. One copy of each form in final format exactly as it will be offered for issuance or delivery in the state of Wisconsin, except for hypothetical data and other appropriate variable material. Ins 6.05(4)(a)5.5. If a form contains variable material or language, a written description identifying the range of the variable material or language. Ins 6.05(4)(a)6.6. A second copy of each form, if the insurer requires an OCI stamped copy for its records. Ins 6.05(4)(a)7.7. A copy of the previously approved form clearly marked “for reference only” if the current form is to supercede the previously approved form. Ins 6.05(4)(a)8.8. If the submission of forms is filed by a third-party on behalf of an insurer, a letter from the insurer, authorizing the third-party to file forms on its behalf. Ins 6.05(4)(a)9.9. A self-addressed return envelope of sufficient size to return one copy of the materials in subds. 1. and 6., to the insurer. Ins 6.05(4)(b)(b) Each electronic submission of forms shall include all of the following: Ins 6.05(4)(b)2.2. A properly completed certificate of compliance and readability in substantially identical format as in Appendix A. Ins 6.05(4)(b)3.3. A filing letter that contains all of the following information: Ins 6.05(4)(b)3.a.a. In the case of a form that alters or replaces a previously filed form, a description of the changes. Ins 6.05(4)(b)3.b.b. The form number and approval or filing date of any form superseded by the new form. Ins 6.05(4)(b)4.4. One copy of each form in final electronic format exactly as it will be offered for issuance or delivery in the state of Wisconsin, except for hypothetical data and other appropriate variable material. Ins 6.05(4)(b)5.5. If a form contains variable material or language, a written description identifying the range of the variable material or language. Ins 6.05(4)(b)6.6. A copy of the previously approved or filed form clearly marked “for reference only” if the current form is to supersede the previously approved or filed form. Ins 6.05(4)(b)7.7. If the submission of forms is filed by a third-party on behalf of an insurer, a letter from the insurer authorizing the third-party to file forms on its behalf. Ins 6.05(4)(c)(c) A submission filed by a rate service organization will be considered as filed on behalf of all affiliated insurers. Ins 6.05(5)(5) Insurer records. Each insurer shall maintain a file of all forms approved or filed under s. 631.20, Stats., for use in Wisconsin until all exposure on the risks insured against has terminated. The file is subject to examination and the commissioner may request that any portion of the file be available for review within ten days of a written request. Ins 6.05(6)(6) Incomplete filing. The commissioner shall reject without further review any filing which does not include all of the items in sub. (4) (a) and (b). Ins 6.05(7)(7) Penalty. Insurers violating the provision of this rule by using unapproved or unfiled forms shall be subject to the penalties in s. 601.64, Stats. Each form issued to an individual policyholder shall constitute a separate violation. Ins 6.05 HistoryHistory: Cr. Register, July, 1958, No. 31, eff. 8-1-58; am. (3), Register, May, 1975, No. 233, eff. 6-1-75; emerg. am. (1), eff. 6-22-76; am. (1), Register, September, 1976, No. 249, eff. 10-1-76; r. and recr. Register, November, 1977, No. 263, eff. 12-1-77; r. and recr. (4), Register, January, 1980, No. 289, eff. 2-1-80; am. (4) (a), (b) (intro.) and 7., Register, February, 1982, No. 314, eff. 3-1-82; cr. (4) (c) and (d), Register, July, 1982, No. 319, eff. 8-1-82; r. and recr. December, 1987, No. 384, eff. 1-1-88; r. (5), renum. (6) to (8) to be (5) to (7), Register, July, 1989, No. 403, eff. 8-1-89; CR 10-076: am. (3) (b), (4) (a) (intro.), 1. to 5., 8., 9., (5), (6), (7), renum. (3) (d), (e), (f) to be (3) (f), (d), (e) and am., renum. (4) (b) to be (4) (c), cr. (4) (b) Register January 2011 No. 661, eff. 2-1-11. Ins 6.05 Appendix A
CERTIFICATE OF COMPLIANCE AND READABILITY
I __________________________, (name), an officer of____________________(company name), hereby certify that I have authority to bind and obligate the company by filing this (these) form(s). I further certify that, to the best of my information, knowledge and belief:
1. The accompanying form(s) as identified by the attached listing comply(ies) with all applicable provisions of the Wisconsin Statutes and with all applicable administrative rules of the Commissioner of Insurance;