List of Acceptable Sample Certificates of Insurance
In Accordance With
The provisions of HB 419, RSA 412:6-b Certificates of Insurance effective January 01, 2012

NOTICE Regarding Certificates of Insurance

Receipt and Review - Insurance industry trade organizations and supporting entities may submit sample certificate of insurance templates in PDF format via SERFF or e-mail to the attention of Denise C Lamy, Director of P&C Consumer and Compliance Services at denise.lamy@ins.nh.gov. Insurance industry trade organizations and supporting entities are not required to be licensed to submit templates. Other office management documents are not reviewable at this time. Filing fees are not required.

Acceptability and Publishing - The New Hampshire Department of Insurance will review the submitted templates for acceptability in accordance with HB 419, RSA 412:6-b effective January 01, 2012. Acceptable templates are shown in the table below. Insurers are not required to submit a filing to the Department advising of their use of an accepted template. Insurers or insurance producers are required to retain record of certificates issued in the policy record file as required by RSA 400-B.

All forms have been saved in Adobe Acrobat Reader format unless otherwise indicated.

 Adobe Acrobat Reader format. You can download a free reader from Adobe.