Name of Reinsurance Intermediary:
Reinsurance Intermediary Providers: A reinsurance intermediary license issued to a firm or association authorizes all members of such firm or association and any designated employees to act as reinsurance intermediary providers under the license. A reinsurance intermediary license issued to a corporation authorizes all officers, and any designated employees and directors thereof, to act as reinsurance providers on behalf of the corporation.
Pursuant to K.S.A. 40-4503, all firms and associations applying for a Kansas reinsurance intermediary license are required to submit the names of all members and designated employees. Additionally, all corporations applying for a Kansas reinsurance intermediary license are required to submit the names of all officers and any designated employees and directors thereof.
Reinsurance Intermediary Firm or Association (e.g., Partnership, LLP, or Association) – Members and Designated Employees:
Reinsurance Intermediary Corporation – Officers and Designated Employees:
For additional members, officers and/or designated employees, expand here to enter.
By checking this box and submitting this form, I affirm that the information provided in this form is accurate and complete. I further affirm that I understand that providing any false information in this filing report, may subject me to administrative action against my license pursuant to K.S.A. 40-4503.
Name of person submitting this form: