FORM FILING QUESTIONNAIRE ENHANCEMENT



NORTH CAROLINA DEPARTMENT OF INSURANCEFORM FILING QUESTIONNAIRE ENHANCEMENTINSURER NAME __________________________________________________________1.INSURANCE COMPANY FILE NUMBER _____________________________________2.SUBLINE/PROGRAM TITLE (IF APPLICABLE) ________________________________3LINE OF INSURANCE: ___________________________________________________4.PROPOSED EFFECTIVE DATE: (NEW) ________________ (RENEWAL) ___________5.EXPLAIN THE PURPOSE OF THIS PRODUCT/FILING. (ATTACH SEPARATE SHEET)6.LIST THE STATES WHERE THIS PRODUCT/FILING HAS BEEN MADE: _________________________________________________________________7.LIST THE STATES THAT HAVE APPROVED THIS PRODUCT/FILING: _________________________________________________________________8.LIST THE STATES THAT HAVE DISAPPROVED THIS PRODUCT/FILING AND THE REASONS.(ATTACH SEPARATE SHEET) ____________________________________________9.I CERTIFY THAT THE INFORMATION CONTAINED IN THIS QUESTIONNAIRE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.________________________________________________________________________SIGNATURE OF COMPANY OFFICER/FILINGS DEPARTMENT HEADFC049 (04-16) ................
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