New Renewal For the period ending April 30: Applicant's Name: Business Entity Type (Ex: partnership, corporation, association, etc): Street Address: City, State, Zip: Phone Number: Email Address: , hereby applies for a license as a rating organization pursuant to K.S.A. 40-956 for the following kinds of insurance or subdivisions thereof: Included with this application filing the following will need to be emailed to kdoi.rf@ks.gov: •A copy of the Applicant's constitution, articles of agreement or association or certificate of incorporation, and its bylaws and rules governing the conduct of its business •A list of its members and subscribers •The name and address of a resident of the state upon whom service of process or orders of the commissioner may be served and an irrevocable agreement to accept such service or notices •A statement of its qualification as a rating organization •$25 application fee will be submitted with this application By submitting this application for licensure as a rating organization, the undersigned, on behalf of the applicant, represents and agrees that: •The information provided with this application is accurate and complete. •The person submitting the application has authority to submit such information. •The rating organization agrees to comply with the laws of the State of Kansas, including,but not limited to, K.S.A. 40-956. •The rating organization is subject to examination pursuant to K.S.A. 40-956. Submitter's Name: Submitter's 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. Submitter's Email Address INSURANCE DEPARTMENT, STATE OF KANSAS OFFICIAL LIST Please complete this form correctly as our records are maintained from the company's official list on file. Name of Company: Date: STATUTORY HOME OFFICE (I)
State of Domicile: Address: Telphone Number: Toll Free Number: Fax Number: MAIN ADMINISTRATIVE OFFICE (II)
Address: Telphone Number: Toll Free Number: Fax Number: MAIL ADDRESS (III)
Address: Telphone Number: Toll Free Number: Fax Number: The following persons occupy the official positions named below (IV)
President's Name: Office Address: Secretary's Name: Office Address: COMPLETED BY: Telephone Number: Email Address:
See instructions below for completing official list
INSTRUCTIONS 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. Kansas Irrevocable Consent to Service of Process Applicant Company Name: Previous Name (if applicable): Business entity type (corporation, partnership, LLC, etc.): Home Office Address: City, State, Zip: FEIN: The undersigned, , a(n) , organized under the laws of , and regulated under the laws of , for purposes of complying with the laws of Kansas relating to the conduct of regulated business within Kansas, pursuant to a resolution adopted by its board of directors or other governing body, hereby irrevocably appoints: and their successors identified herein, or where applicable appoints the required agent so designated herein as its agent in Kansas upon who may be served any noticie, process or pleading as required by law as reflected herein any action or proceeding against it in Kansas; and does hereby consent that any lawful action proceeding against it may be commenced in any court of competent jurisdiction and proper venue within Kansas; and agrees that any lawful process against it which is served under this appointment whall be of the same legal force and validity as if served on the entity directly. This appointment shall be binding upon any seccessor to the above-named entity that acquires the entity's assets or assumes it 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 Kansas. The entity hereby waives all claims of error by reason of such service. Applicant Company's Officer's Certificate and Attestation One of the two Officers (listed below) of the Appllicant Company must carefully read the following 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 jurisdictions that all of the forgoing is true and correct, executed at (county): (state): . Date: 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. Full Legal Name of President: Date: 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. Full Legal Name of Secretary: Service of Process Agent Name of Entity: Phone Number: Fax Number: Email Address: Mailing Address: Street Address:
