State of Kansas Risk Purchasing Group

APPOINTMENT OF ATTORNEY TO ACCEPT SERVICE AND DESIGNATION

On this date, ("the Group"), a purchasing group organized under the laws of the State of , having notified the Insurance Commissioner of the state of Kansas of its intention to do business in this State as a purchasing group pursuant to the Federal Liability Risk Retention Act of 1986, hereby appoints the Insurance Commissioner of the State of Kansas, any successor in office, and any authorized deputy for its true and lawful attorney, in and for the State of Kansas, upon whom all legal documents or process in any proceeding against it may be served. Such service of process shall be of the same legal force and validity as if served personally upon the Group.

The Group designates:

(Name)


(Address)


(Phone)


(Email)

as its officer, agent or other person to whom shall be forwarded all legal documents or process served upon the Insurance Commissioner of the State of Kansas, any successors in office, or any authorized deputy, for the Group. This designation shall continue in full force and effect until superseded by a new writen designation filed with the Insurance Commissioner.

This appointment and designation is made pursuant to a resolution by the Group's governing body authorizing it, and a certified copy of the resolution is emailed to kdoi.rf@ks.gov. This appointment shall be binding upon any person or corporation which as successor acquires the Group's assets or assumes is liabilities, by merger or consolidation or otherwise.

This appointment may be withdrawn only upon a writen notice of termination and, in any event, shall not be terminated by the Group or its successor so long as any contracts or liabilities or duties arising out of contracts entered into by the Group while it was doing business in this State are in effect.


IN WITNESS OF THIS APPOINTMENT AND DESIGNATION, the Group, in accordance with the resolution of its Board of Directors, duly passes on 04/19/2024, and caused the same to be subscribed and attested in its name by this President and Secretary, at the City of in the State of on 04/19/2024


(Name of Purchasing Group)

By:
President
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.

Secretary
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.


By submitting this application there is additional steps necessary to complete prior the approval of the referenced Risk Purchasing Group.