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.
Name of Member Insurer, Member Self-Insurer
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Kansas Automobile Assigned Claims Plan
Manager of KAIP's Signature