Name of Purchasing Group

Group's Federal Employer I.D. No.

Check box(es) below to show which Purchasing Group registration info changed
Purchasing Group Name
Address
Phone Number
Email Address
New Information
Effective date of change

Delete Current Insurer
List Co name & NAIC No.
New Information
Effective date of change

Add New Company
List Co name & NAIC No.
New Information
Effective date of change

Delete Agent
List Agent's name,address, phone number & email address
New Information
Effective date of change

Change Agent
List Agent's name,address, phone number & email address
New Information
Effective date of change

Delete State
state
New Information
Effective date of change

Change Purchasing Group Officer
name
New Information
Effective date of change

Change Purchasing Group Contact
List name, address, phone number & email address
New Information
Effective date of change

Other
Describe
New Information
Effective date of change

Email any additional information to kid.addpc@ks.gov

Officer Certification:
I certify that the information in this report and any attachments included with it is completed and correct.

(Signature of officer of the Purchasing Group)
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.
(Date)

(Officer Title)
(Name of Contact)
(Contact's Email)
(Contact's Phone)

Our web address is: insurance.kansas.gov
Questions Contact: kid.addpc@ks.gov

Risk Retention Act of 1986, 3903(d)(2) requires submission of any Purchasing Group registration information changes. Failure to file properly may result in a compliance action against the purchasing group.

INSTRUCTIONS FOR COMPLETING FORM:

Name of the Purchasing Group, Group contact name and email address
The name fo the purchasing group should be shown exactly as it was on the original registration from, DO NOT USE ABBREVIATIONS. ALL SUBMISSIONS MUST BE COMPLETE THESE SECTIONS.

Purchasing Group Name, Address, Phone Number & Email Address
Click appropriate box of item that is changing. In the New Information section, please include email address, as all correspondence will now be done electronically.

Delete Current Insurer
If deleting existing company, click box. In the New Information section, please include the company's name and NAIC number.

Add New Company
If adding a new insurance company, click box. In the New Information section, please include the company's name and NAIC number.

Delete Agent
If deleting an agent, click box. In the New Information section, please provide name, address, phone number and license number.

Change Agent
If adding a new agent, click box. In the New Information section, please provide name, address, phone number, email address and license number.

Delete State
If withdrawing from a state that group is presently registered in, click box.

Change Purchasing Group Officer
If the group is changing an officer, click box. In the New Information section, provide new officers name, address and new position.

Change Purchasing Group Contact
If the group's contact is to be changed, click box. In the New Information section, provide new contact's name address, phone number and email address.

Other (Describe)
For all other changes, click box. In the New Information section, provide necessary information including name, address, phone number and email address.