Change in Registration for Purchasing Groups

Due within 10 days of effective date of change.


Name of Purchasing Group

Group's Federal Employer I.D. No.

Check box(es) below to show which Purchasing Group registration info changed

  

  

  

  
Effective date of change 


Company Name 
NAIC No.  
Company Name 
NAIC No.  
Company Name 
NAIC No.  
Effective date of change  


Company Name 
NAIC No.  
  
Company Name 
NAIC No.  
  
Company Name 
NAIC No.  
  
Effective date of change


Agent Name 
Address    Phone 
Email    NPN 

Agent Name 
Address    Phone 
Email    NPN 

Agent Name 
Address    Phone 
Email    NPN 

Effective date of change


Agent Name 
Address    Phone 
Email    NPN 

Agent Name 
Address    Phone 
Email    NPN 

Agent Name 
Address    Phone 
Email    NPN 

Effective date of change 


State Information 
Effective date of change 


Removed Officer 
New Officer 
Effective date of change 


Name 
Address 
Phone 
Email 

Effective date of change 


Describe Change


Effective date of change 

Email any additional information to kdoi.rf@ks.gov

Officer Certification:
I certify that the information in this report, including any attachments, is complete and correct.


(Signature of Purchasing Group Officer)
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.
05/29/2025
(Date)






Our web address is: insurance.kansas.gov
Please contact us at kdoi.rf@ks.gov or 785-296-7844 if you have any questions or concerns.

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 of the purchasing group should be shown exactly as it was on the original registration form. If there have been multiple name changes, the purchasing group's most recent name change should be provided. DO NOT USE ABBREVIATIONS. PLEASE COMPLETE ALL SECTIONS.

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

Delete Current Insurer
Click box if deleting existing company. Please provide the company's name and NAIC number in the New Information section.

Add New Company
Click box if adding a new insurance company. Please provide the company's name and NAIC number in the New Information section.

Delete Agent
Click box if deleting an agent. Please provide the name, address, phone number and license number in the New Information section.
If you've submitted an Agent Change, you will receive a separate email with instructions to finalize the change with NIPR (National Insurance Producer Registry). Changes MUST be finalized with NIPR to be valid.

Change Agent
Click box if adding a new agent. Please provide name, address, phone number, email address and license number in the New Information section.
If you've submitted an Agent Change, you will receive a separate email with instructions to finalize the change with NIPR (National Insurance Producer Registry). Changes MUST be finalized with NIPR to be valid.

Delete State
Click box if withdrawing from a state in which the group is presently registered.

Change Purchasing Group Officer
Click box if the group is changing an officer. Please provide the new officer's name, address and new position in the New Information section.

Change Purchasing Group Contact
Click box if the group's contact is to be changed. Please provide new contact's name, address, phone number and email address in the New Information section.

Other
Please click box for all other changes. Please provide the necessary information including name, address, phone number and email address in the New Information section.