Name of Risk Retention Group: Principal Business Address: Mailing Address (if different): NAIC Code: FEIN: Date of Organization/Charter: APPLICATION CONTACT Name: Phone: Email: RISK RETENTION GROUP INFORMATION 1. List any other name(s) by which the Risk Retention Group is known (if none, answer none). 2. The Risk Retention Group is a corporate or other limited liability association whose primary activity consists of assuming and spreading all, or any portion, of the liability exposure of its members. The Risk Retention Group is organized for the primary purpose of conducting this activity as described. Yes No 3. The Risk Retention Group is chartered and licensed as a liability insurance company under the laws of the State of , and is authorized to engage in the following lines and/or classifications of insurance under the laws of its chartering State: 4. The Risk Retention Group affirms that is does not exclude any person from membership in the Group solely to provide for members of the Group a competitive advantage over such a person. Yes No 5. Ownership of the Risk Retention Group consists of one or the other of the following: the owners of the Group are the only persons who comprise the membership of the Group and who are provided insurance by the Group. the sole owner of the Group is. (Name and Address of Organization) 6. The Risk Retention Group affirms that members are engaged in businesses or activities similar or related with respect to the liability to which such members are exposed by virtue or related, similar or common business, trade, product, services, premises or operations. Yes No Please give a general description of businesses or activities engaged in by the Groups members. 7. The Risk Retention Group affirms that the activities of the Risk Retention Group do not include the provision of insurance other than: (a) liability insurance for assuming and spreading all or any portion of the similar or related liability exposure of another Risk Retention Group (or a member of such other Risk Retention Group) engaged in business or activities which qualify such other Risk Retention Group (or member) under item #6 above or membership in this group. Yes No 8. List the names, addresses and positions of each officer and director of the Risk Retention Group: Name Position with RRG Address Identify and give the telephone number of the office or director of the Risk Retention Group who can be contacted for any information regarding the management of the insurance activities of the Group: Name Position Held Phone Number Email Address 9. List the name, address, telephone number and Federal Employer Identification Number (FEIN) of the company responsible for managing the insurance operations of the Risk Retention Group and the contact person at the company )in none, answer none): Name FEIN Address Designated Contact Name Phone Number Email Address 10. List the name(s), NPN(s) and home states of the licensed insurance agent(s) or broker(s) responsible for marketing the Risk Retention Group's insurance policies and the state(s) in which they are licensed, including Kansas: (if none, answer none). Name NPN State(s) 11. The Risk Retention Group affirms that it will comply with the unfair claim settlement practices laws of Kansas. Yes No 12. The Risk Retention Group affirms that it will pay, on a non-discriminatory basis, applicable premium and other taxes, which are levied on such Group under the laws of Kansas. Yes No 13. The Risk Retention Group affirms that it has designated the Kansas Insurance Commissioner to be its agent soley for the purpose of receiving service of legal documents or process. Yes No 14. The Risk Retention Group affirms that it will submit to examination by the Kansas Insurance Commissioner to determine the Group's financial condition, if the Insurance Commissioner of the Group's chartering State has not begun or does not initiate an examination within 60 days after a request by the Kansas Insurance Commissioner. Yes No 15. The Risk Retention Group affirms that it will comply with a lawful order issued in a delinquency proceeding commenced by the Kansas Insurance Commissioner upon a finding of financial impairment, or in a voluntary dissolution proceeding. Yes No 16. The Risk Retention Group affirms that it will comply with the laws of Knasas concerning deceptive, false or fraudulent acts or practices, including any injunctions regarding such conduct obtained from a court of competent jurisdiction. Yes No 17. The Risk Retention Group affirms that it will with an injunction issued by a court of competent jurisdiction upon petition by the Kansas Insurance Commissioner alleging that the Group is in hazardous financial condition or is financially impaired. Yes No 18. The Risk Retention Group affirms that it will provide th efollowing notice, in at least 10-point type, in any insurance policy issued by the Group: NOTICE This policy is issued by your risk retention group. Your risk retention group may not be subject to all of the insurance laws and regulations of your State. State insurance insolvency guaranty funds are not available for your risk retention group. Yes No 19. As part of this application, the Risk Retention Group will submit to KDOI.RF@ks.gov a copy of the plan of operation or a feasiblity study that has been filed with its chartering state. This plan or study includes the name of the state in which the Group is chartered, as well as the Group's principal place of business, and such plan or study further includes the coverage's, deductibles, coverage limits, rates, and rating classification systems for each line of insurance the Group intends to offer. The Group also affirms that it will promptly submit to the Kansas Insurance Commissioner any revisions of such plan or study to reflect any changes to the plan if the Group intends to offer any additional lines of liability insurance, including any change in the designation of the State in which it is chartered. Yes No 20. As part of this application, the Risk Retention Group will submit a copy of its annual financial statement submitted to its chartering State to KDOI.RF@ks.gov. The annual financial statement will be certified by an independent public accountant and include a statement of opinion on loss and loss adjustment expense reserves made by a member of the American Academy of Actuaries or a qualified loss reserve specialist. The certification and statement of opinion on loss and loss adjustment expense reserves will be submitted to the Kansas Insurance Commissioner by the date it is required to be submitted to its chartering state. 21. The Risk Retention Group affirms that it will not solicit or sell insurance to any person in Kansas who is not eligible for membership in the Group. Yes No 22. The Risk Retention Group affirms that it will not solicit or sell insurance in Knasas, or otherwise operate in this State, if the Group is in hazardous financial condition or is financially impaired. Yes No 23. The Risk Retention Group affirms that it will not issue any insurance policy in this State, which provides coverage prohibited generally by statute of Kansas or declared unlawful by the highest court of this State whose law appllies to such policy. Yes No 24. The Risk Retention Group affirms that it not directly owned by, or have members that are, an insurance company. Yes No 25. The Risk Retention Group affirms that it will comply with all other appicable state laws. Yes No 26. The Risk Retention Group affirms that it will notify the Kansas Insurance Commissioner as to any subsequent changes in any of the items included in this form. Yes No The Insurance Commissioner of the State of Kansas is authorized to make use ofany of the powers established under the insurance code of this state to enforce the laws of this state so long as those powers are not specifically preempted by the product liability risk retention act of 1981, as amended by the risk retention amendments of 1986. Such authorization includes, but is not limited to, the commissioner's administrative authority to investigate, issue subpoenas, conduct depositions and hearings, issue orders and impose penalties. With regard to any investigation, administrative proceedings, or litigation, the commissioner can rely on the procedural law and regulations of the state. The injunctive authority of the commissioner in regard to risk retention groups is restricted by the requirement that any injunction be issued by a court of competent jurisdiction. After submitting this application, you will be taken to a payment portal to complete the non-refundable $250 application fee. The undersigned hereby swear and affirm that the foregoing statements and information regarding this Risk Retention Group are true and correct: CERTIFICATION: Signed on this day of , 20 (Name), the President or Chief Exeucutive Officer of (Applicant Risk Retention Group Name) 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. Signed on this day of , 20 (Name), the Secretary of (Applicant Risk Retention Group Name) 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. Applicant Company Name NAIC No FEIN Uniform Certificate of Authoriy Application (UCAA) Uniform Consent to Service of Process Original Designation Amended Designation (must be submitted directly to states) Applicant Company Name: Previous Name (if applicable): Statutory Home Office Address: City, State, Zip: NAIC CoCode: The Applicant Company named above, organized under the laws of , and regulated under the laws of for purposes of complying with the laws of the State(s) designate hereunder relating to the holding of a certificate of authority or the conduct of an insurance business within said State(s), pursuant to a resolution adopted by its board of directors or other governing body, hereby irrevocably appoints the officers of the State(s) and their successors identified in Exhibit A, or where applicable appoints the required agent so designated in Exhibit A hereunder as its attorney in such State(s) upon whom may be served any notice, process or pleading as required by law as reflected on Exhibit A in any action or proceeding against it in the State(s) so designated; and does hereby consent that any lawful action or proceeding against it may be commenced in any court of competent jurisdiction and proper venue within the State(s) so designated; and agrees that any lawful process against it which is served under this appointment shall be of the same legal force and validity as if served on the entity directly. This appointment shall be binding upon any successor to the above named entity that acquires the entity's assets or assumes its liabilities by merger, consolidation or otherwise; and shall be binding as long as there is a contract in force or liability of the entity outstanding in the State. The entity hereby waives all claims of error by reason of such service. The entity names above agrees to submit an amended designation form upon a change in any of the information provied on this power of attorney. Applicant Company Officer's Certification and Attestation One of the two Officers (listed below) of the Applicant Company must read the following very carefully and sign: 1. I acknowledge that I am authorized to execute and am executing this document on behalf of the Applicant Company. 2. I hereby certify under penalty of perjury under the laws of the applicable jurisdiction that all of the foregoing is true and correct, executed at . Date Full Legal Name of President Signature of 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. Date Full Legal Name of Secretary Signature of 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. Uniform Certificate of Authority (UCAA) Uniform Consent to Service of Process Exhibit A AL - Commissioner of Insurance # and Resident Agent * AK - Director of Insurance # AZ - Director of Insurance # ^ AR - Resident Agent * AS - Commissioner of Insurance # CO - Resident Agent * CT - Commissioner of Insurance # DE - Commissioner of Insurance # DC - Commissioner of Insurance and Securities Regulation # or Local Agent * FL - Chief Financial Officer # ^ GA - Commissioner of Insurnce and Safety Fire # and resident Agent * GU - Commissioner of Insurance # HI - Insurance Commissioner # and Resident Agent * ID - Director of Insurance # ^ IL - Director of Insurance # IN - Resident Agent * ^ IA - Commissioner of Insurance # AK - Commissioner of Insurance ^ KY - Secretary of State # LA - Secretary of State # MD - Insurance Commissioner # ME - Resident Agent * ^ MI - Resident Agent * MN - Resident Agent ~ MS - Commissioner of Insurance and Resident Agent * BOTH are required MO - Director of Insurance # MT - Resident Agent * NE - Officer of Company * or Resident Agent * NH - Commissioner of Insurance # NV - Commissioner of Insurance Commission # ^ NJ - Commissioner of Banking and Insurance # ^ NM - Superintendent of Insurance # NY - Superintendent of Financial Services # NC - Commissioner of Insurance # ND - Commissioner of Insurance # ^ OH - Resident Agent * OR - Resident Agent * OK - Commissioner of Insurnce # PR - Commissioner of Insurance # RI - Superintendent of Insurance^ SC - Director of Insurance # SD - Director of Insurance # TN - Commissioner of Insurance # TX - Resident Agent * UT - Resident Agent * ^ VT - Resident Agent * VI - Lieutenant Governor/Commissioner # WA - Insurance Commissioner # WV - Secretary of State # WY - Commissioner of Insurance # # - For the forwarding of Service of Process received by a State Officer complete Exhibit B listing by state the entities (one per state) with full name and address where service of process is to be forwarded. Use additional pages as necessary. Exhibit not required for New Jersey and North Carolina. Florida accepts only an individual as the entity andrequires an email address. New Jersey allows but does not require a foreign insurer to designate a specific forwarding address on Exhibit B. SC will not forward an individual by name; however, it will forward to a position, e.g., Attention: President (or Compliance Officer, etc). Washington required an email address on Exhibit B. * - Attach a completed Exhibit B listing the Resident Agent for the Applicant Company (one per state). Include state name, Resident Agent's full name and street address. Use additional pages as necessary. (DC* requires an agent within a ten-mile radius of the District), (MT requires an agent to reside or maintain a business in MT). ^ - Initial pleadings only. MA will send the required form to the Applicant Company when the approval process reaches that point. ~ - Minnesota does not forward Service of Process. Service of Process must be accomplished using the procedures set forth in MN State. 45.028. Applicant Company should complete Exhibit B to provide a resident agent address that Commerce will keep on file. Resident agent must have a Minnesota address. Uniform Certificate of Authority (UCAA) Uniform Consent to Service of Process Exhibit B Complete for each state indicated in Exhibit A: State: Name of Entity: Phone Number: Fax Number: Email Address: Mailing Address: Street Address: State: Name of Entity: Phone Number: Fax Number: Email Address: Mailing Address: Street Address: State: Name of Entity: Phone Number: Fax Number: Email Address: Mailing Address: Street Address: State: Name of Entity: Phone Number: Fax Number: Email Address: Mailing Address: Street Address: State: Name of Entity: Phone Number: Fax Number: Email Address: Mailing Address: Street Address: Resolution Authorizing Appointment of Attorney BE IT RESOLVED by the Board of Directors or other governing body of (Applicant Company Name) this day of , 20 , that the President or Secretary of said entity be and are hereby authorized by the Board of Directors and directed to sign and execute the Uniform Consent to Service of Process to give irrevocable consent that actions may be commenced against said entity in the proper court of any jurisdiction in the state(s) of in which the action shall arise, or in which plaintiff may reside, by service of process in the state(s) indicated above and irrevocably appoints the officer(s) of the state(s) and their successors i such offices or appoints the agent(s) so designated in the Uniform Consent to Service of Process and stipulate and agree that such service of process shall be taken and held in all courts to be as valid and binding as if due service had been made upon said entity according to the laws of said state. CERTIFCATION I, , Secretary of , state that this is a true and accurate copy of the resolution adopted effective the day of , 20 by the Board of Directors or governing board at a meeting held on the day of , 20 or by written consent dated day of , 20 . Date 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.
