This letter will serve as this company's subscription to the Kansas Automobile Insurance Plan.

In subscribing to the Plan it is understood and agreed:

1. That the undersigned company hereby authorizes and empowers the manager of the Kansas Automobile Insurance Plan to act as our filing agent with respect to rates, rules and forms for risks to be insured under the uniform rates, rules and forms provisions of the Kansas Automobile Insurance Plan;

2. That this subscription shall automatically terminate if at any time any carrier is permitted to transact automobile insurance in the State of Kansas without becoming a subscriber to this Plan;

3. That this subscription shall automatically terminate if at any time any subscribing carrier resigns as a subscriber to the Plan.

*Automobile Liability Insurance includes Bodily Injury, Property Damage, Personal Injury Protection (No-Fault) and Uninsured Motorists Coverages. Automobile Liability Insurance may include Comprehensive and Collision Coverages.


Name of Company


Home Office

By
Signature for Company
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Authorized Officer


Date ACCEPTED

Kansas Automobile Insurance Plan


Manager of KAIP's Signature