**CERTIFICATION OF ANNUAL**

**ACCOUNTING STATEMENT**

**(Carrier)**

This is to certify that I have reviewed this accounting statement and to
the best of my knowledge and belief:

1.  The statement was prepared in conformity with guidelines issued by
    the Office of Personnel Management and fairly presents the financial
    results of this reporting period in conformity with those
    guidelines;

2.  The costs included in the statement are actual, allowable, allocable
    and reasonable in accordance with the terms of the contract and with
    the cost principles of the Federal Employees Health Benefits
    Acquisition Regulation and the Federal Acquisition Regulation;

3.  Income, rebates, allowances, refunds and other credits made or owed
    in accordance with the terms of the contract and applicable cost
    principles have been included in the statement;

4.  If applicable, the letter of credit account was managed in
    accordance with 5 CFR part 890, 48 CFR chapter 16, and OPM
    guidelines.

CARRIER
NAME\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

NAME OF CHIEF EXECUTIVE NAME OF CHIEF FINANCIAL

OFFICER (TYPE OR PRINT) OFFICER (TYPE OR PRINT)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

SIGNATURE OF CHIEF EXECUTIVE SIGNATURE OF CHIEF FINANCIAL

OFFICER (TYPE OR PRINT) OFFICER (TYPE OR PRINT)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DATE SIGNED DATE SIGNED

**CERTIFICATION OF ANNUAL**

**ACCOUNTING STATEMENT**

**(Underwriter)**

This is to certify that I have reviewed this accounting statement and to
the best of my knowledge and belief:

1.  The statement was prepared in conformity with guidelines issued by
    the Office of Personnel Management and fairly presents the financial
    results of this reporting period in conformity with those
    guidelines;

2.  The costs included in the statement are actual, allowable, allocable
    and reasonable in accordance with the terms of the contract and with
    the cost principles of the Federal Employees Health Benefits
    Acquisition Regulation and the Federal Acquisition Regulation;

3.  Income, rebates, allowances, refunds and other credits made or owed
    in accordance with the terms of the contract and applicable cost
    principles have been included in the statement;

4.  If applicable, the letter of credit account was managed in
    accordance with 5 CFR part 890, 48 CFR chapter 16, and OPM
    guidelines.

CARRIER
NAME\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

NAME AND TITLE OF RESPONSIBLE CORPORATE OFFICIAL

(TYPE OR PRINT)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

SIGNATURE OF RESPONSIBLE CORPORATE OFFICAL

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DATE SIGNED