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[File and Use under Article 3.42, paragraph (c)] To the best of my knowledge and belief, such filed form, contract, or policy complies in all respects with provisions of the Texas Insurance Code and the adopted rules and regulations that are applicable to such policy contract, certificate, application, rider, endorsement, or other form being filed.

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[Exempt Forms] Such filed form, contract, or policy complies in all respects with all applicable laws and rules. I certify that none of these forms is deceptive or misleading and none contains exceptions or conditions that unreasonably or deceptively affect the risk purported to be assumed in the general coverages of the policy. I also certify that the use of these forms will be discontinued in the event of future change in laws or rules which would prohibit the use of such forms.

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[Corrections] No changes have been made to the forms previously submitted other than those identified and marked. A summary of changes, including a description of any deleted text, is attached.

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[Resubmission] No changes have been made to the forms previously submitted other than those identified and marked. A summary of changes, including a description of any deleted text, is attached.

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[Exact Copy] The form is an exact copy of Form [Insert form number] for [Insert company name] which was approved for use in the State of Texas on [Insert date of approval]. No changes or modifications have been made to this form other than the company information, and/or a direct translation of the form to a foreign or Braille text. Additionally, I certify that the form complies with all applicable laws and rules.

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[Similar to Previously Approved Form] The form is an exact copy of Form [Insert form number] for [Insert Company Name] for use in the State of Texas on [Insert date of approval]. No changes have been made to this form other than those identified and marked. A summary of changes, including a description of any deleted text, is attached. Additionally, I certify that, other than the noted changes, the form complies in all respects with all applicable laws and rules.

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[Substitution] The form is a substitution for Form [Insert form number] which was approved or filed as exempt in the State of Texas on [Insert date]. A summary of changes, including a description of any deleted text, is attached. No changes or modifications have been made to the form other than those identified and marked. The original version of this form has not been issued or otherwise used in Texas and will not be used in Texas at anytime.

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[Supplemental Coverage] The policy form will only be marketed and issued to supplement in-force accident and sickness coverage in accordance with 28 TAC 3.3080.