This government document is issued by Division of Insurance (DOI) for use in Massachusetts
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https://www.mass.gov/doc/2001-05-forms-submitted-for-approval-pursuant-to-chapter-175-section-2b/download?_gl=1*1fulawr*_ga*MTY2NTg2Nzk5LjE3MzE2NzIwODE.*_ga_MCLPEGW7WM*MTczMTY3MjA5NS4xLjEuMTczMTY3NjYxOS4wLjAuMA..&_ga=2.110070339.790269867.1731672081-166586799.1731672081