This government document is issued by Division of Insurance (DOI) for use in Massachusetts
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https://www.mass.gov/doc/srb-90-02-instructions-for-filing-life-and-individual-accident-and-health-forms/download?_gl=1*soiw6u*_ga*MTY2NTg2Nzk5LjE3MzE2NzIwODE.*_ga_MCLPEGW7WM*MTczMTY3MjA5NS4xLjEuMTczMTY3NDc1NC4wLjAuMA..&_ga=2.64596585.790269867.1731672081-166586799.1731672081