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

• 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 any relevant bond information or other evidence of financial ability to pay judgments against the applicant to

KDOI.RF@ks.gov
By submitting this application, the undersigned represents that the information provided herein is accurate and complete, that they possess sufficient authority to submit this application on behalf of the Applicant, and that they will notify the Kanas Insurance Department with any changes in the Applicant’s status affecting qualification to possess a Certificate of Self-Insurance and any changes to the Applicant’s contact information.

Name of Individual Submitting
Filer:
Title:
Date: 11/21/2024