1. Applicant's Name:
Street Address:
City,State, Zip:
Phone Number:
Email:
In support of this Application for Certificate of Self-Insurance, the Applicant affirms the following:

• APPLICANT has on this date more than twenty-five (25) vehicles registered in Kansas and will continue to have registered more than twenty-five (25) vehicles in Kansas.
• APPLICANT has the responsibility to immediately notify the Kansas Insurance Department 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 is a participant in the Kansas Automobile Assigned Claims Plan, as required by K.S.A. 40-3116.
APPLICANT has sent any relevant bond information or other evidence of financial ability to pay judgments against the applicant to kdoi.rf@ks.gov

Name of Individual Submitting
Filer:
Title:
Date: 04/28/2024