KANSAS AUTOMOBILE ASSIGNED CLAIMS PLAN

ACKNOWLEDGEMENT OF NOTICE OF MEMBERSHIP


The undersigned member Insurer or member Self-Insurer hereby acknowledges receipt of notice of membership in the Kansas Automobile Assigned Claims Plan by causing its corporate name to be hereunto subscribed b its president or other authorized officer. Each member Insurer or member Self-Insurer hereby authorizes the Governing Committee of the Kansas Automobile Assigned Claims Plan to levy such assessments and to take such actions as deemed by it to be appropriate to assure the operation of the Plan on a fair and equitable basis consistent with K.S.A. 40-3116.


Date Acknowledged


Name of Member Insurer, Member Self-Insurer


Address


By
By typing your name above, you are signing this electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.


Title

Kansas Automobile Assigned Claims Plan


Manager of KAIP's Signature