Cybersecurity Certification

Cybersecurity Certification

Company Name*

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Email*

example@example.com

State of Maryland

Information Security Program Certification

Pursuant to §33–103(j), I First Name Last Name , an authorized officer of Name of Company (the "Company") hereby certify to the best of my knowledge, information, and belief, that:

Select One of the Following:

Domestic Company: the company is in compliance with the requirements of the Insurance Data Security Act set forth in Md. Code Ann. Ins. Art. § 33-103(j)(1) and (2) and will maintain for examination by the Commissioner all records, schedules and data supporting this certification for a period of 5 years from the date submitted.Foreign Company: the company is in compliance with the requirements of the Insurance Data Security Act set forth in Md. Code Ann. Ins. Art. § 33-103(j)(1) and (2) and will maintain for examination by the Commissioner all records, schedules and data supporting this certification for a period of 5 years from the date submitted.Foreign Company: the company is exempted from completing this certification because pursuant to Md. Code Ann. Ins. Art. § 33-103(k)(1), it is domiciled in another United States insuring jurisdiction that has adopted a law or regulation that is substantially similar to this section; is subject to that law or regulation; is required to file a certification of compliance with its domestic regulator under that law or regulation; and actually files that required certification with its domestic regulator.Foreign Company: the company is exempted from completing this certification because pursuant to Md. Code Ann. Ins. Art. § 33-103(k)(2), it is a member of an insurance holding company system, as defined in Md. Code Ann. Ins. Art § 7–101; and has implemented and is subject to an information security program that has been approved and is maintained by another carrier within the same insurance holding company system that meets all of the criteria set forth in §33–103(k)(1).Domestic or Foreign Company: the company is deemed to have complied with § 33-103 because pursuant to Md. Code Ann. Ins. Art. § 33-106(a)(1), it is subject to, governed by, and compliant with the privacy, security, and breach notification rules issued by the U.S. Department of Health and Human Services, 45 C.F.R. Parts 160 and 164, established under the Health Insurance Portability and Accountability Act of 1996, and the Health Information Technology for Economic and Clinical Health Act, and the company maintains nonpublic information in the same manner as protected health information.

I further attest that I am an authorized officer of the Company and have been duly authorized by all necessary corporate acts to execute this Form on behalf of the Company and, thereby to, bind the Company to the certifications made herein.

Signature*

Officer Signature Upload

If you are not an authorized officer of the company, please upload the officer's signature here. In the box above, please write an "X".

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