Kansas Department of Insurance

APPLICATION FOR RESIDENT CERTIFICATE OF SELF-INSURANCE Pursuant to K.S.A. 40-3104

Pursuant to Kansas Statutes Annotated 40-3104, the undersigned hereby applies for a certificate of Self-Insurance as a public Motor Carrier of property, household goods, or passengers, or a private Motor Carrier of property. Any person in whose name more than 25 motor vehicles are registered in Kansas may qualify as a self-insurer by obtaining a certificate of self-insurance from the commissioner of insurance. The undersigned applicant affirms they meet all the requirements for a certificate of self-insurance included in K.S.A. 40-3104.

* APPLICANT has the responsiblity to immediately notify the Kansas Department of Insurance at any time the total number of registered vehicles is less than this requirement.
* APPLICANT is possessed and will continue to be possessed of the ability to pay any liability imposed by law against APPLICANT arising out of the ownership, operation, maintenance or use of any motor vehicle registered in its name.
*APPLICANT certifies compliance with the coverage requirements of K.S.A. 3116.
*APPLICANT has sent evidence of financial ability to pay judgments against the applicant to kdoi.rf@ks.gov

Name of Applicant:
Name of Organization:
Address:
Form of Organization:
Fiscal Year End Date:

Please answer ALL the following questions:
1. Are you currenlty operating as a self-isurer? Yes No If so, how long?

2. Do you have a claims department for investigating and adjusting claims? Yes No
If no, please provide a brief description of how claims are investigated and adjusted:

3. Have you set up a reserve fund for accident claims? Yes No If yes:
a. Under what category or caption does it appear on your financial statements?
b. What basis is used for determining the amount of reserve established for claims? If no, please provide a brief narrative of how your outstanding liablity is determined:

4. Do you maintain any excess insurance coverage to limit your exposure?Yes No If yes, provide:
a. Name of company providing coverage:
b. Line of coverage:
c. Amount of coverage:
d. Submit a copy of the certificate of insurance showing company name, insured's information, amount of coverage, and policy or account number to kdoi.rf@ks.gov

CLAIMS HISTORY INFORMATION

Provide the number of registered vehicles:

Provide the following information on accidents and claim history for the past two(2) years involving vehicles registered to this entity that either occurred in Kansas, or involve Kansas residents:

Years

A. Number of incidents:

Personal Injury

Property Damage

TOTAL NUMBER OF INCIDENTS

B. Number of Claim Occurences:
Personal Injury

Closed, settled w/ payment

Closed, settled w/o payment

Open and pending

TOTAL PERSONAL INJURY CLAIM OCCURENCES

Property Damage

Closed, settled w/ payment

Closed, settled w/o payment

Open and pending

TOTAL PROPERTY DAMAGE CLAIM OCCURENCES

Total number of accidents for which no claims were made:

C. Payment of Claims:

Amount of Personal Injury claims paid

Amount of Property Damage claims paid

TOTAL AMOUNT OF CLAIMS PAID

D. Reserves established for Pending Claims:

Pending Personal Injury reserve amount

Pendng Property Damage claims reserve amount

TOTAL AMOUNT OF RESERVE FOR PENDING CLAIMS

Are there any motor vehicle judgements open and unsatisfied?Yes No If yes:
How many? Total amount of unsatisfied judgements:

Are there any other judgements open and unsatisfied against you?Yes No

Does the entity self-insure any other risks related to the business' operation, function, or any other exposure that would impact or otherwise be relevant to the company's overall financial stability?Yes No
If yes, explain

*The applicant is also required to submit an audited annual financial statement showing consolidated report and profit and loss statement as certified by a public accountant, or a Form 10-K by the applicant with the Securities and Exchange Commission. These records are part of the application and should be submitted via email to the Kansas Department of Insurance at kdoi.rf@ks.gov. If a Form 10-K is available online, you may provide a url to access the Form in lieu of a paper copy.
URL

By signing below, the applicant affirms that everything presented in this applicantion and subsequent supporting documentation is true and correct to the best of their knowledge. The applicant agrees to presently and continually meet the requirements contained in this application for certificate of self-insurance as a Motor Carrier, pursuant to K.S.A. 66-1,128, and will notify the Kansas Department of Insurance of any material changes to the company's eligibility.

Signature:

Title:

Email Address:

Phone Number: