Advertising Annual Certification of Compliance

Advertising annual certification of compliance

LAH314 | 0126
Instructions
- Do not submit a hard copy in the mail.
- You will receive a confirmation copy of your submission by email.
- All fields marked with * are required and must be filled.
Reporting Year*
This is usually the previous calendar. You may submit for the reporting calendar year after January 1.
TDI license number
Company name*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Certification

By signing this form, I am certifying:
1. I am familiar with the requirements of 28 Texas Administrative Code (TAC) Chapter 21, Subchapters A and B as they pertain to advertising.
2. The company maintains an advertising file in accordance with 28 TAC Section 21.11(a).
3. To the best of my knowledge, information, and belief, the advertisements used during this calendar year complied or were made to comply fully with these Subchapters and the insurance laws of Texas in accordance with 28 TAC Section 21.116(b).
Signature*

Clear
Printed name*
Title of Company Officer
Email*
example@example.com
Should be Empty:

Advertising annual certification of compliance