(1) Statements substantially similar to the
following shall be included on the same page as the numeric summary and signed
by the applicant, or the policy owner in the case of an illustration provided
at time of delivery, as required in this rule.
(2) A statement to be signed and dated by the
applicant or policy owner reading as follows: "I have received a copy of
this illustration and understand that any non-guaranteed elements illustrated
are subject to change and could be either higher or lower. The agent has told me they are not
(3) A statement to be signed and dated by the
insurance producer or other authorized representative of the insurer reading as
follows: "I certify that this illustration has been presented to the
applicant and that I have explained that any non-guaranteed elements
illustrated are subject to change. I
have made no statements that are inconsistent with the illustration. "