Content of certificate of assumption.

(a) The certificate of assumption shall include at least the following:

(1) The name of the insurer (transferring insurer) which is transferring the insurance obligation to an assuming insurer.

(2) The name and mailing address of the insurer (assuming insurer) which is acquiring the insurance obligation from the transferring insurer.

(3) A statement that the obligations and liabilities of the transferring insurer are transferred to the assuming insurer.

(4) The date the transfer takes effect.

(5) A statement that the certificate of assumption is part of and attached to the contract issued by the original insurer.

(6) A statement as to whom and where future premiums are to be paid.

(7) An execution statement.

(8) One officer’s signature.

(9) The form number in the lower left hand corner of the certificate of assumption.

(b) The following is a sample certificate of assumption:

NAME OF COMPANY STREET ADDRESS CITY, STATE

CERTIFICATE OF ASSUMPTION

NAME OF COMPANY is a party to an agreement between the NAME OF COMPANY and NAME OF COMPANY providing for the assumption by the NAME OF COMPANY of all obligations and liabilities under this policy (certificate) of insurance issued by NAME OF COMPANY. By virtue of this agreement, the liabilities and obligations of NAME OF COMPANY under this policy (certificate) of insurance issued by the company are now directly those of NAME OF COMPANY. All benefits under the policy (certificate) remain the same.

All premiums now or hereafter due on this policy (certificate) are payable to NAME OF COMPANY at its home office or executive office or to its duly authorized agents.

This Certificate of Assumption forms a part of and is to be attached to your policy (certificate).

IN WITNESS WHEREOF, NAME OF COMPANY has caused this Certificate of Assumption to be executed this

_____________________ day of ______________________ .

President

FORM NO.