INACTIVE AGENT APPLICATION

K.S.A 40-4903(e)(5) allows for an individual insurance licensee to be exempt from continuing education requirements while on Inactive Status. An Inactive Agent is a licensed agent that affirms to the Commissioner of Insurance that he or she will not conduct any acts toward transacting the business of insurance while on inactive status. The period of inactivity allowed is a continuous period of time of not more than four (4) years starting from the date inactive status is granted by the Commissioner. Inactive status is granted to a licensee only one time.


NPN: 
Residence Address: 
        
          
Phone: 
Email: 

Reason to maintain license on an inactive basis: (optional): 

Dates requested for inactive status (the dates you enter must be equal to not more than four years):    

By signing below, I certify that I am currently an “inactive agent” as defined by K.S.A. 40-4902(j), and will not do any act toward transacting the business of insurance during the term of inactive service specified above.

After Completing this form, print it and affix your signature and date. It should be emailed to kdoi.licensing@ks.gov with “Inactive Status Application” in the subject line.

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Signature 

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Date

For requirements on returning to active status, visit the Department’s website at insurance.kansas.gov