Pursuant to the provision of K.S.A. 40-3106(b),

the (Name of Company)

of (Address of Home Office)

hereby declares that its motor vehicle liabilty policies wherever issued shall be deemed to provide the insurance required by K.S.A. 40-3107, when the vehicle covered by such policy is operated in the State of Kansas.

The company under stands that this declaration is filed as a condition of its continued transaction of business within the State of Kansas.

(Name)

(Title of Authorized Officer)

(Signature)
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)