Insurance Data Security Law Annual Certification Form

Pursuant to Indiana Code § 27-2-27-20, each licensee domiciled in this state that does not meet the exemption requirements set forth in Indiana Code § 27-2-27-26, shall annually, on or before April 15, submit a written statement to the Commissioner certifying that the licensee is in compliance with the requirements set forth in Indiana Code §§ 27-2-27-16 through 27-2-27-20. Please complete the certification below:

Section 1 – Contact Information

EIN *

NAIC #

Contact Name *

Phone * ###-###-####

Email *

Section 2 – Certification

Licensee Name *

I hereby certify that the licensee above is duly organized under the laws of the State of Indiana and is in compliance with the requirements set forth in Indiana Code §§ 27-2-27-16 through 27-2-27-20. However, I acknowledge that to the extent the licensee has identified areas, systems, or processes that require material improvement, updating or redesign, the licensee is required to document the identification and remedial efforts planned and underway to address such areas, systems, or processes; and that such documentation must be available for inspection by the Commissioner. I hereby acknowledge that for examination purposes, the licensee named above shall maintain all records, schedules and data supporting this certificate for five (5) years. By submitting this form, I certify that I am authorized to submit this form on behalf of the licensee named above. *

Title *

Type Signature *