The undersigned Insurer hereby elects (*) to become a member of the Kansas Basic Property Insurance Inspection and Placement Program, the Kansas All-Industry Placement Facility, and the Joint Reinsurance Association, and pledges its ful participation and cooperation in carrying out the Kansas FAIR Plan pursuant to the Program approved by the Insurance Commissioner.

The undersigned Insurer designates the Kansas All-Industry Placement Facility as its lawful agent for the purposes of filing on its behalf the applicable rates, rules and forms to be used in writing Basic Property and Casualty Insurance and procedures for administering the operation of the Kansas FAIR Plan while it is a participating member.


NAME OF INSURER


ADDRESS OF INSURER


AUTHORIZED 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.


TITLE


PRINTED NAME


DATE SIGNED


AREA CODE TELEPHONE NO. OF AUTHORIZED SIGNOR

(*) Insurers electing not to voluntarily participate may insert the word "not" in this space.