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.