Pursuant to Kansas Statutes Annotated 40-3106, the undersigned hereby applies for a certificate of Self-Insurance as a Nonresident Self-Insurer. 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. 40-3106.

• For each state where both the APPLICANT is authorized as a self-insurer and one of the APPLICANT’s vehicles registered in the state may be driven in Kansas, APPLICANT has sent a copy of the self-insurer authorization by an agency of the state to KDOI.RF@ks.gov.
• APPLICANT certifies compliance with the coverage requirements of K.S.A. 40-3107.
• APPLICANT has sent evidence of financial ability to pay judgments against the applicant via financial reports to KDOI.RF@ks.gov .

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

Please answer all of the following questions:

1. Are you currently operating as a self-insurer? 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
1. If yes: Under what category or caption does it appear on your financial statements?  AND
2. What basis is used for determining the amount of reserve established for claims?
3. If no, please provide a brief narrative of how your outstanding liability is determined:
4. Do you maintain any excess insurance coverage to limit your exposure? Yes  No
 If yes, provide:

1. Name of company providing coverage:
2. Line of coverage:
3. Amount of coverage:
4. Submit a copy of the certificate of insurance showing company name, insured’s information, amount of coverage, and policy or account number.

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:

Are there any motor vehicle judgements open and unsatisfied? Yes  No If yes:
How many?    Total amount of unsatisfied judgement: $
Are 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 filed 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 application 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 Nonresident self-insurer, pursuant to K.S.A. 40-3106, and will notify the Kansas Department of Insurance of any material changes to the company’s eligibility.

Signature:
Title:
Email Address:
Phone Number: