Application for registration as an Administrator for firms that administer self-funded plans that are not regulated by Article 38, Kansas Statute Annotated (see K.S.A. 40-3810 as amended by 2017 Senate Bill 22)
Type of Entity: Corporation
Legal Name of Applicant:
Federal Tax Identification Number:
Contact Person Name and Title:
Business Address(Do not use PO Box):
Business City, State and Zip:
Mailing City, State and Zip:
State of Domicile:
Below is a list of all entities for which your firm provides administrative services in the State of Kansas. Please include the full name and address of each entity, and date your firm initiated administrative services.\
Name of Entity,
Address Of Entity,
Date Services Initiated
List all states in which each plan is doing business or covers individuals.
Confirmation of registration will be mailed within 30 days of receipt of completed registration form. Registration expires December 31st annually and re-registration using this form is required. No fees required.
I certify that, under penalty of perjury, I am the person named herein and know the contents thereof, and that all of the information submitted in this application is true and complete. I attest that I have the authority and capacity to execute this certification on behalf of the registrant. I am aware that submitting false information or omitting pertinent or material connection with this registration is grounds for denial of registration.
I further certify that is not administering or planning to administer self-funded plans and other entities regulated under Article 38 of the Kansas Statutes Annotated. If is planning to administer or will administer self-funded plans involving church or governmental plans, an appropriate TPA license will be secured.
Name of registrant
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.
(Must be signed by at least two (2) officers of the registrant)