State of Kansas Purchasing Group Notice Form Completed Appointment of Attorney to Accept Service and Designation after application submission $250 Non-Refundable notice fee
1. List the legal name of the Purchasing Group: 2. List any other name(s) by which the Purchasing Group is known or may be doing business in this state or any other state: 3. Indicate the form of the organization (i.e., corporation, partnership, association) and the state in which organized: 4. a) The Purchasing Group is domiciled in the state of: b) Address: 5. Physical address, mailing address and email address of the administrative offices of the Purchasing Group are reported in the SBS application. 6. The Purchasing Group intends to purchase the following lines and classifications of liability insurance: Aircraft Liability Excess Liability Owners & Contractors Protective Liability Rail Road Protective Liability Auto Liability General Liability Pollution Liability Umbrella Liability Contractual Liability Liquor Liability Product Liability Rail Road Protective Liability Employment Practices Liability Cyber Liability Professional Liability (Other than Med-mal) Other 7. The Purchasing Group intends to purchase the liability insurance described in Item #6 above from the following company or companies: Give full name of the company and its state of domicile. Name of Company: State of Domicile: Admitted Non-Admitted Name of Company: State of Domicile: Admitted Non-Admitted Name of Company State of Domicile: Admitted Non-Admitted Name of Company: State of Domicile: Admitted Non-Admitted Name of Company: State of Domicile: Admitted Non-Admitted 8. Does the Purchasing Group purchase liability insurance listed in Item #7 above only for its group members and only to cover their similar or related liability exposure? Yes No 9. The Purchasing Group must be composed of members whose business or activities are similar or related with respect to the liability to which members are exposed by virtue of any related, similar or common business, trade, product, services, premises or operations. Provide a general dsecription of business or activities engaged in by Purchasing Group members: Accountants Bankruptcy Trustee/Receivers Dental HMOS Marina Operator Agricultural Commercial Vehicles Directors & Officers Home Inspectors & Security Non Profit Organization Architects & Engineers Consultants Educational Institutions Hospital & Clinics Nursing Homes Attorneys Contractors Financial Institutions Insurance Professionals Office Professionals Asbestos/Environmental Daycare Funeral Directors Landowners & Developers Pest Control Aviation Dealers Extended Warranty Healthcare Practitioners Manufactureres & Distruibutors Physicians Property Owners & Managers Public Entities Publishing Real Estate Professionals Reposserssors Restaurants & Hotels Retail Food Delivery Service Providers Sports & Recreation Stockbrokers Travel Trucking Wholesalers & Retailers Other 10. The Purchasing Group has designated the Insurance Commissioner of this State to be its agent for the purpose for receiving service of legal documents or process by executing a document in substantially the same form as the sample document. 11. List the Purchasing Group Administrator 12. Appoint agents via NIPR. The Purchasing Group shall notify the Insurance Commissioner of any subsequent changes in any of the items included in this form. The undersigned hereby swear and affirm that the foregoing statements and information regarding the (Name of Purchasing Group) are true and correct. President of the Purchasing Group 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 of the Purchasing Group 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. APPOINTMENT OF ATTORNEY TO ACCEPT SERVICE AND DESIGNATION The ("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) (City, Town or Village) (State and Zip Code) as its officer, agent or other person to shom 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 superceded by a new written 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 Kid.addpc@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 apointment may be withdrawn only upon a written 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 , 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 (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.
