Nev. Admin. Code § 686A.474
The following statements must be included on the same page as the numeric summary and must be signed by the applicant, or the policy owner if an illustration is provided at the time of the delivery of the policy, and the insurance agent or broker. The statements must be in substantially the following form:
I, the applicant or policy owner, have received a copy of this illustration and understand that any nonguaranteed elements illustrated are subject to change and could be higher or lower. The insurance agent or broker has informed me they are not guaranteed.
I, the insurance agent or broker, certify that this illustration has been presented to the applicant or policy owner and that I have explained that any nonguaranteed elements illustrated are subject to change. I have made no statements that are inconsistent with the illustration.
Nev. Admin. Code § 686A.474
NRS 679B.130, 686A.015