CERTIFICATION STATEMENT
REQUEST FOR INFORMATION ON FLORIDA CLAIMS DATA BY THE
INSURANCE CONSUMER ADVOCATE
I,
______________________________________________________________(print
name),
on
behalf
of
_________________________________________________________________(company name) state that the
information responsive to the Insurance Consumer Advocate’s 2015 Request for Information regarding Florida
Claims Data is true and accurate to the best of my knowledge. I understand that the information transmitted by the
company stated herein will be used by the Insurance Consumer Advocate to conduct an independent investigation
for the above purposes. I additionally certify that I am an executive officer of the above company, acting within my
authority in executing this Certification Statement, and have conducted a thorough review of the said company’s
records and systems to determine the truth of the responsive information.
By: _______________________________________
Print Name: ________________________________
Title: _____________________________________
Date: _____________________________________