AppendixB.

FORM CR-1

CERTIFICATE OF CERTIFIED REINSURER

I, _______________________________, ________________________________

(name of officer) (title of officer)

of______________________________________________, the assuming insurer

under a reinsurance agreement with one or more insurers domiciled in

_________________________________________, in order to be considered for

(name of state)

approval in this state, hereby certify that

_______________________________________________ ("Assuming Insurer"):

(name of assuming insurer)

1. Submits to the jurisdiction of any court of competent jurisdiction within the State of Connecticut for the adjudication of any issues arising out of the reinsurance agreement, agrees to comply with all requirements necessary to give such court jurisdiction, and will abide by the final decision of such court or any appellate court in the event of an appeal. Nothing in this paragraph constitutes or should be understood to constitute a waiver of Assuming Insurer’s rights to commence an action in any court of competent jurisdiction in the United States, to remove an action to a United States District Court, or to seek a transfer of a case to another court as permitted by the laws of the United States or of any state in the United States. This paragraph is not intended to conflict with or override the obligation of the parties to the reinsurance agreement to arbitrate their disputes if such an obligation is created in the agreement.

2. Designates the Insurance Commissioner of the State of Connecticut as its lawful attorney upon whom may be served any lawful process in any action, suit or proceeding arising out of the reinsurance agreement instituted by or on behalf of the ceding insurer.

3. Agrees to provide security in an amount equal to 100% of liabilities attributable to U.S. ceding insurers if it resists enforcement of a final U.S. judgment or properly enforceable arbitration award.

4. Agrees to provide notification within 10 days of any regulatory actions taken against it, any change in the provisions of its domiciliary license or any change in its rating by an approved rating agency, including a statement describing such changes and the reasons therefore.

5. Agrees to annually file information comparable to relevant provisions of the NAIC financial statement for use by insurance markets in accordance with section 38a-88-4a(b)(7)(B) of the Regulations of Connecticut State Agencies.

6. Agrees to annually file the report of the independent auditor on the financial statements of the insurance enterprise.

7. Agrees to annually file audited financial statements, regulatory filings, and actuarial opinion in accordance with section 38a-88-4a(b)(7)(D) of the Regulations of Connecticut State Agencies.

8. Agrees to annually file an updated list of all disputed and overdue reinsurance claims regarding reinsurance assumed from U.S. domestic ceding insurers.

9. Is in good standing as an insurer or reinsurer with the supervisor of its domiciliary jurisdiction and maintains capital in excess of the jurisdiction’s highest regulatory action as evidenced by certification of its domiciliary regulator.

Dated: ______________ _________________________________________

(name of assuming insurer)

BY: __________________________________

(name of officer)

__________________________________

(title of officer)

(Effective August 6, 2013)