- In accordance with N.C. Gen. Stat. § 58-89A-60(a)(5), execution of this form is required at the time of application.
- In accordance with N.C. Gen. Stat. § 58-89A-70(d)(4), execution of this form is required within 120 days after the end of each fiscal year.
- In accordance with N.C. Gen. Stat. § 58-89A-70(e)(2), the Commissioner may require the execution of this form in order for a licensee to maintain licensure. If required, this form must be filed with the North Carolina Department of Insurance no later than 60 days after the end of each quarter of the fiscal year.
Applicant Information
Attestation
I, the undersigned, attest that the applicant or licensee named above is in compliance with all requirements under Article 89A of Chapter 58 of the North Carolina General Statutes regarding the payment of wages, taxes, workers’ compensation coverage, and employee benefits.
Note: If any obligations are in dispute with a client and the disputed amount is material when considered in the context of the applicant or licensee’s most recent audited financial statement, then the applicant or licensee must disclose the nature of the dispute causing the obligations to be unpaid and the amount of money in controversy. Any such disclosures must be attached to this form.
Please submit the completed and signed attestation to:
Christine.Williams@ncdoi.gov