The
(Name of Company)


(Street Address)

(City)

(State)

herby requests that the Corporation Commission of the State of Kansas be notified of the company's admission to the State and of its authorization to write Automobile Residual Bodily Injury, Personal Injury Protection and Property Damage Liability Insurance.


(Date)


(Signature)
By typing your name above, you are signing this electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.


(Name)

(Official Position)


To: The Corporation Commission - State of Kansas

The above company has been admitted to Kansas and is authorized to write Automobile Residual Bodily Injury, Personal Injury Protection and Property Damage Liability Insurance.