Pursuant to 2021 amendments to K.S.A. 40-4903(c)(5), insurance producers who hold a life insurance license solely for the purpose of selling pre-need funeral insurance or annuity products shall provide a certification from an officer of each insurance company which has appointed the agent that the agent has not transacted any insurance for the company other than pre-need funeral insurance or annuity products. Companies can utilize the form below to electronically submit the required certification to the Kansas Insurance Department.

Agents appointed with your company will not be able to renew their pre-need only insurance license until a certification from your company is received by the Department. If received after the licensee’s biennial renewal date, the licensee will be required to pay a reinstatement fee in order to renew their license.

Company Certification of Agent’s Sale of Pre-Need Insurance Only


Company cocode: 
Address: 
City:   State:   Zip: 

RE: 
NPN: 
Biennial Period:  to 

To the Kansas Insurance Department, Producer Licensing Division:
By submitting this form, the undersigned certifies that he/she is a duly appointed officer of the above-named company (“Company”) and has had performed a diligent search of the records of the Company. Based on the results of that search, the undersigned certifies, pursuant to K.S.A. 40-4903(c)(5), that the agent identified on this form has not transacted any insurance business other than sales of pre-need insurance for the Company during the Biennial Period stated above.*

Name of Officer: 
Title: 
Email: 
Telephone Number: 

 By checking this box and submitting this form, I affirm that the information provided in this form is accurate and complete.

Date: 01/18/2022

*If the licensee has transacted insurance business other than pre-need sales for your company, please contact the Department at kid.licensing@ks.gov