Name of Pool: Name of DBA, if using: 1. The pool is required to have a minimum Membership of five or more municipalities (as defined in K.S.A. 75-6102) per K.S.A. 12-2617. Yes, this pool meets this requirement. No, this pool does not meet this requirement. [Exhibit 1 Example: Current Membership List] File Named: 2. The pool is required to have a minimum annual Kansas gross premium of $250,000 for each category written of (1) property insurance, (2) motor vehicle liability and physical damage insurance, (3) workers compensation insurance and employers liability insurance, and (4) all other casualty insurance under article 11 of chapter 40 of the Kansas Statutes Annotated per K.S.A. 12-2618(d). Yes, this pool meets this requirement. Please indicate which of the above types of insurance the pool is providing. No, this pool does not meet this requirement, because the pool offers none of the above listed types of insurance. No, this pool does not meet this requirement. [Exhibit 2 Example: Premium Totals by Member and Line] File Named: 3. If the pool offers workers compensation benefits, then the pool and each member is required to have executed a binding agreement to comply with the provisions of the workers compensation act per K.S.A. 12-2618(e). Yes, this pool meets this requirement. No, this pool does not meet this requirement. No, this pool does not offer workers compensation benefits. [Exhibit 3 Example: Current Binding Agreement] File Named: 4. The pool is required to have a minimum annual Kansas gross premium of $1,000,000 (this amount is in addition to the requisite amount from 2, if any) if group sickness and accident insurance is offered by the pool per K.S.A. 12-2618(d). Yes, this pool meets this requirement. No, this pool does not meet this requirement. No, this pool does not offer group sickness and accident benefits. [Exhibit 4 Example: Premium Totals by Member and Line] File Named: 5. The pool may offer group life insurance if at the date of issue the coverage will insure at least 60% of the eligible participants or the total number of persons covered will exceed 600 per K.S.A. 12-2618(d). Yes, this pool meets this requirement. No, this pool does not meet this requirement. No, this pool does not offer group life insurance. [Exhibit 5 Example: Participant Totals] File Named: 6. For all lines of coverage, all members of the pool shall be jointly liable for the payment of claims to the extent of the assets of the pool per K.S.A. 12-2618(e). Yes, this pool meets this requirement. No, this pool does not meet this requirement. [Exhibit 6 Example: Current Governing documents or Indemnity Agreement] File Named: 7. A confirmation of specific and aggregate excess insurance or adequate surplus funds per K.S.A. 12-2618(h). Yes, this pool has specific and aggregate excess insurance. No, this pool does not meet this requirement, and intends to provide evidence of adequate surplus funds, to be approved by the Commissioner. No, this pool does not meet this requirement. The pool requests a determination that it has adequate surplus funds. The pool has an exemption from the Department. [Exhibit 7 Example: Certificate of Insurance/Policy Declaration Page/Current Exemption] File Named: 8. The pool Administrator is required to furnish a sufficient fidelity bond to the pool per K.S.A. 12-2627(a). Yes, this pool meets this requirement. No, this pool does not meet this requirement. [Exhibit 8 Example: Certificate of Insurance/Policy Declaration Page] File Named: 9. If the pool utilizes a revolving fund account, then the Service Agent is required to furnish a fidelity bond to the pool that is sufficient to protect all moneys placed in the revolving fund per K.S.A. 12-2627(b). Yes, this pool meets this requirement. No, this pool does not meet this requirement, and does not utilize a revolving fund. No, this pool does not meet this requirement. [Exhibit 9 Example: Certificate of Insurance/Policy of Declaration Page] File Named: 10. Please state the name and qualifications of the current pool administrator per K.S.A. 12-2620(c). Name: Qualifications 11. The pool will notify the Kansas Department of Insurance of any change in administrator or in the membership of the board of trustees within 30 days of such change per K.S.A. 12-2618(b). Yes, this pool acknowledges this requirement. No, this pool does not acknowledge this requirement. 12. Annually or within 30 days of change, provide the terms of the specific and aggregate excess insurance contracts of the pool per K.S.A. 12-2620(c). Yes, this pool meets this requirement. No, this pool does not meet this requirement. [Exhibit 12 Example: Certificate of Insurance/Policy of Declaration Page] File Named: 13. The pool will notify the Commissioner of any change in bylaws wihin 30 days of such change per K.S.A. 12-2618(a). Yes, this pool meets this requirement. No, this pool does not meet this requirement. [Exhibit 13 Example: Current in force By-Laws] File Named: 14. Has the list of pool member municipalities changed in the preceding year? Yes. No. [Exhibit 14 Example: Current Member List] File Named: 15. The pool will notify the Commissioner of any change in reinsurance within 30 days of such change per K.S.A. 12-2618(h). Yes, this pool acknowledges this requirement. No, this pool does not acknowledge this requirement. [Exhibit 15 Example: Current Reinsurance Agreement] File Named: 16. The pool will notify the Commissioner of any change in the address of books and records within 30 days of such change per K.S.A. 12-2618(c). Yes, this pool acknowledges this requirement. No, this pool does not acknowledge this requirement. 17. The pool will provide an audited financial statement within 180 days after end of fiscal year per K.S.A. 12-2620(b). Yes, this pool acknowledges this requirement. No, this pool does not acknowledge this requirement. 18. The pool shall submit financial statement as the Commissioner may require per K.S.A. 12-2620(b). Currently, those statements are required quarterly by the Department of Insurance Financial Surveillance Division. Yes, this pool acknowledges this requirement. No, this pool does not acknowledge this requirement. 19. The pool is not borrowing any money in the name of the pool without advising the Commissioner K.S.A. 12-2627(e). Yes, the pool has advised or will advise of any borrowing. No, the pool has not borrowed. 20. The pool will notify the Commissioner if a member terminated or the pool cancels a membership. The pool will maintain coverage of the terminated/cancelled member for 30 days after notice to the Commissioner or until the Commissioner gives notice that the former member has procured workers' compensation and employer's liability insurance elsewhere, whichever occurs first. K.S.A. 12-2626. Yes, this pool meets this requirement. No, this pool does not meet this requirement. This pool does not transact workers compensation. 21. Any person or agency soliciting for the pool shall be licensed in every line of insurance the pool offers. K.S.A. 12-2628. Yes, this pool meets this requirement. No, this pool does not meet this requirement. [Exhibit 21 Example: Agent/Agency Information] File Name: Agent Name: NPN: 22. Pay gross premium tax 90 days after end of the state's fiscal year upon annual KS gross premium collective at the rate of 1% per K.S.A. 12-2624. a. Annual Kansas Gross Premium collected for the preceding calendar year $ b. Premiums returned due to cancellations $ c. Dividends returned to members $ d. Expenditures for the purchase of specific and aggregate excess insurance $ e. Net taxable premiums (Line A minus lines B, C, and D) $ f. Tax due at 1% $ Please send exhibits evidencing compliance with the above to kdoi.rf@ks.gov. Please number the exhibits to correspond with numbered requirements (i.e., label exhibits evidencing the requisite gross premium of prompt 2 as either 2 or 2.a. if multiple documents are necessary.) Person responsible for completion of this form: Name: Email: Phone:
