Continuation of License as a Premium Finance Company - State of Kansas

Your license to operate as a Premium Finance Company in the state of Kansas may be continued as of May 1 of every year provided that your company complies with Kansas law as respects the continuation procedure and upon compliance and submission of the following material by email to

1. Payment to the Commissioner of the $100 continuation fee as required by K.S.A. 40-2604. As stated in such statute, failure to pay the continuation fee before April 1 of each year could result in revocation of your license. You will be directed to a payment portal after submission of this application.

2. Annual Report (Financial Statement) – The report shall contain certain information concerning the business and operation during the preceding calendar of fiscal year within the state. This report shall be filed on or before the first day of April. The time for filing may be extended by the Commissioner of Insurance for a period not in excess of sixty (60) days. The format of this report is not prescribed by law. Therefore, a company may use or continue to use the same or similar financial report as used in previous year. (This report is not the annual report that is required by the Secretary of State.)

3. Official List – A copy of an Official List, which identifies any person occupying an official position in your company.

4. Location of Records – A statement which identifies the person(s) in charge of Kansas operations and the location of your records pertaining to Kansas.

5. Changes in Articles of Incorporation or Bylaws – Any changes which have occurred in your Articles of Incorporation or Bylaws.

This fee, application and all other requested material or information should be received in our office before April 1 of every year.


a premium finance company organized under the laws of the State of , hereby applies for the continuation of the license authorizing and empowering the above entitled premium finance company to transact business pursuant to the provisions of the Kansas Insurance Premium Finance Company Act. Provided with this application is the premium finance company's annual report as required by K.A.R. 40-14-3.

, being duly sworn, deposes and says that they are the above described officer of said premium finance company and that all information in this application and in documents provided thereto is correct to the best of their knowledge, information and belief.

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.

Location of Records


Please complete this form correctly as our records are maintained from the company's official list on file.




The following persons occupy the official positions named below (IV)

See instructions below for completing official list


(I) STATUTORY HOME OFFICE: As identified with the Certificate of Authority issued by your domicilary state.
(II) MAIN ADMINISTRATIVE OFFICE: Location of the company's main administrative office.
(III) MAIL ADDRESS: Address the company wants mail to go to if other than the Main Administrative Office address; may be a P.O. Box number and the associated zip code.
(IV) Furnish information for only the positions and addresses set out. Do not alter or insert additional positions or addresses. If no one holds a position listed, indicate "NONE". This Department is to be notified promptly of any changes that occur in the positions, addresses and/or telephone numbers during the year.