Notification of Value-Added Product or Service Pilot or Testing Program

1. You are required to provide the Insurance Company NAIC #(s) or the Insurance Agent NPN #(s). Which will you be providing?

2. Insurance Company NAIC #(s)

2. Insurance Agent NPN #(s)

3. Name the Insurance Company(ies) associated with the NAIC #(s) or Name the Insurance Agent(s) associated with the NPN #(s)

4. Contact Name

5. Contact Phone Number

6. Contact Email Address

7. Briefly describe the service or product

8. Is this service or product being offered in conjunction with a specific product/type of insurance? (Check all that apply)

9. Who will be eligible for the service or product?

10. Where will the service or product be offered? (statewide or specific region)

11. When will the service or product be offered?

12. What is your cost for the service or product?

13. What is the cost, if any, to the consumer?

14. Which of the following describes the service or product? The pilot/testing program will determine if the service or product described above will: (please check all that apply)

15. By checking the box below and clicking the “Submit” button, I acknowledge the following:

The pilot or testing program complies with Ohio Revised Code 3901.213(D)(3)
The pilot or testing program may proceed unless the Superintendent objects in writing within 21 days after receiving notice
If the pilot or testing program proceeds, the pilot or testing program may continue for no more than one year
The responses provided may be a public record, subject to Ohio’s Public Records Act